South Florida Plastic Surgery Associates - Don R. Revis, MD











Breast Augmentation Revision

Correcting Problems with Breast Implants

Although board certified in the entire spectrum of plastic surgery, Dr. Revis has chosen to focus his practice on cosmetic plastic surgery, which he practices exclusively. Within that spectrum, he has developed a special interest in breast augmentation and its potential problems. Breast augmentation surgery — both new and revisionary procedures — are the most common procedures performed by Dr. Revis (400-450 breast implant procedures each year). In the interest of your safety, he only performs surgery in a fully accredited ambulatory surgery center or a local hospital with M.D. anesthesiologists.

Dr. Revis has been selected as one of only 35 members for the Mentor Worldwide LEAD Council. Read more about Mentor's LEAD Program Advisory Board.

Capsular Contracture and Bottoming Out Repair: Before and After Photos Capsular Contracture and Bottoming Out Repair: Before and After Photos
Before After
Photos show a 36 year old patient with bilateral capsular contracture and bottoming out, at pre-op and three months post-op. Bilateral capsulectomy and pocket switch from subglandular to submuscular were performed, with implant exchange from moderate profile saline filled to 350cc to moderate plus profile saline filled to 450cc.

Breast augmentation is a procedure that is often assumed to be simple in nature and execution but is actually quite complex. Proper surgical technique and attention to detail are essential to good results, and too often these are overlooked. In his opinion, this is why Dr. Revis sees so many patients who are dissatisfied with their augmentation or have developed one or more complications. There is no such thing as a simple breast augmentation, and an attitude of "seen one, seen them all," commonly held by many plastic surgeons, simply will not suffice when dealing with the subtle complexities and intricacies of breast augmentation.

As a similar example, twenty years ago rhinoplasty was treated the same way, and the usual result was that every nose done by the same plastic surgeon turned out to look exactly the same, regardless of the patient's facial proportions, preferences, ethnic background, etc. Over the past twenty years an evolution in our thought processes has resulted in the realization that rhinoplasty is a multi-dimensional, complex surgery that must be individualized for each patient. Dr. Revis believes that breast augmentation is long overdue for such an evolution as well, and some plastic surgeons are farther behind in their approach than others. For instance, the notion that the surgeon knows best in the selection of the implant size for his or her patients is ridiculously outdated. We should never presume to know what is best for our patients in this regard. Our responsibility is to present the facts to our patients and guide them in making their own decision that is in their best interests. Similarly, no one incision is right for every patient, and one location for implant placement (be it above the muscle, subpectoral, or totally submuscular) does not satisfy every patient's needs.

The three most common reasons for breast implant revisions — changing implant size, improving the natural feel and appearance of the breasts, and correcting capsular contracture — should be minimized by a careful and thorough approach to breast augmentation. Dr. Revis' systematic approach has minimized these revisions in his own  practice while improving patient outcomes and satisfaction ratings. He feels that the real focus should be in prevention of these problems rather than in their treatment. However, breast implants are like any other man-made implantable medical device (such as heart valves and artificial joints), and realistically, some patients will require revisionary procedures. Plastic surgeons must be aware of the potential problems that may exist and be equipped to properly diagnose and treat patients so that an acceptable outcome is achieved.

In treating your specific complaint, our pledge to you is to properly evaluate the problem and to recommend one or more ways in which we can correct the problem. Breast augmentation revision surgery is certainly more complex than primary (initial) augmentation, and you should realize that the proper time for the correct operation to be performed is the first time. However, Dr. Revis has developed considerable experience with the correction of breast augmentation problems and may very well be able to improve your results.

The cornerstone of Dr. Revis' approach is to individualize treatment to your specific circumstances and goals and to ensure that you have an adequate understanding of the issues involved so that you are able to make a fully informed decision. This will help you achieve the appearance you desire with the least invasive procedure available, thus creating a mutually rewarding experience. Dr. Revis invites you to visit his office for a complimentary consultation to discuss the procedure in greater detail. You are also invited to email Dr. Revis with your questions, or we can mail you more detailed information regarding the procedure.

As you consider plastic surgery, one of the most important decisions you will make is choosing your surgeon. Our pledge to you is to provide the latest, state of the art cosmetic plastic surgery in a safe and professional environment. Dr. Revis is a recognized specialist in the field of cosmetic plastic surgery and is board certified by the American Board of Plastic Surgery, the only plastic surgery board recognized by the American Board of Medical Specialties. He is also an active member of the American Society of Plastic Surgeons and has also been named among "America's Top Surgeons" by the Consumers' Research Council of America. 

Our goal is to provide you with the ultimate patient experience. Our well-trained staff will help you understand your procedure, our financial policies, the scheduling of your surgery, and your post-operative care. We are available to assist you during our regular office hours, Monday through Friday. Dr. Revis is also available 24 hours a day to post-surgical patients; he will give you his cell phone number after surgery so that you will always be able to reach him with any questions or concerns you might have during your recovery.

The need for breast augmentation revisions stem from a number of sources but fall into several broad categories:

  • Problems with surgical placement or implant position
  • Problems with the patient's tissue characteristics
  • Problems with the implants themselves

When a problem does arise, the proper correction focuses first and foremost on carefully diagnosing why the problem exists. Many patients have a problem that falls into more than one of the above categories, creating an even more challenging situation. Within the three broad categories mentioned above, specific problems include:

Problems with Surgical Placement or Implant Position

  • Implant asymmetry with one implant higher than the other or located too far medially or laterally with respect to the other implant

Example of breast implant asymmetry Example of breast implant asymmetry Example of breast implant asymmetry

  • Bottoming out (implants being positioned too low or too lateral on the chest wall in relation to the nipple position) may represent overdissection of the pocket in the region of the inframammary crease during surgery, cutting of the lower portion of the pectoralis muscle, or may occur naturally with implants that are placed above the muscle or only subpectorally (partially submuscular) when compared to total submuscular placement of the implants

Bottoming out of breast implant Bottoming out of breast implants

  • Synmastia (aka symmastia, uniboob or breadloafing) usually represents overdissection in the medial region of the breasts over the sternum (aka the breastbone) in an attempt to create better cleavage

Example of synmastia (breadloafing)

  • Implants that remain too high post-operatively (and do not drop or settle into the correct position)

Example of breast implants that are placed too high

  • Implants that are too widely spaced apart, lacking desirable cleavage or falling into the armpits upon lying down

Example of breast implants that are too widely spaced

Problems with the Patient's Tissue Characteristics

  • Snoopy deformity (prominence of the nipple-areolar complex characterized by herniation of some of the breast tissue into the nipple-areolar complex, named after its similarity to the cartoon character Snoopy) should be addressed during the initial operation but occasionally only becomes apparent post-operatively
     
  • Areolas that appear too large before or after augmentation do not necessarily require revision, but should be addressed during the initial consultation and treated during the initial operation if it is of concern to the patient

Example of wide areaolas

  • Tuberous breasts (characterized by a narrow base of the breast, a widening of the breast near the nipple-areolar complex, and a short or deficient inframammary crease) should be addressed during the initial operation because if overlooked or not treated properly will inevitably lead to an unsatisfactory outcome

Example of tuberous breasts

  • Mondor's Cord (aka Mondor's disease, named after French surgeon Henri Mondor, actually represents a thrombophlebitis of the superficial vein(s) of the breast, typically between the nipple and the inframammary crease and usually causing significant discomfort) usually does not require a revisionary technique but is mentioned here for completeness. It is usually treated with anti-inflammatory medications and warm compresses until spontaneous resolution occurs
     
  • Thinning of the breast tissue as a result of aging, pregnancy, or breastfeeding (which may result in the implants becoming more visible and the appearance less natural)
     
  • An elongation of the skin and sagging of the breasts over time as tissue elasticity is lost as a result of aging, sun damage or smoking

Example of breast skin that has stretched over time

  • Pre-existing natural asymmetry not corrected during the initial operation. Most breasts differ from one another, sometimes greatly. This may be a difference in size, shape or position and is rarely perfectly corrected during surgery. However, asymmetries should be properly diagnosed and documented preoperatively in an attempt to correct the asymmetry as much as possible during surgery.

Example of natural breast asymmetry present after augmentation

Problems with the Implants Themselves

  • Deflation (rupture of an implant) with saline implants this is usually quite obvious because the augmentation effect is rapidly lost over the course of a day or two. Although the saline is harmlessly absorbed by the body, replacement of the implant should be performed within a few weeks to keep the pocket from shrinking. With silicone implants, rupture may be less obvious and may require further testing to confirm, such as an ultrasound or MRI. Breast implants used today have a full replacement warranty that will provide you with replacement implant(s) at no cost to you. Depending on how long it has been since your original operation, you may also be eligible for financial assistance towards the operating room costs as well.

Example of breast implant deflation Example of breast implant deflation

  • Capsular contracture occurs when your body forms a thick scar around the implant(s). This may occur on one or both sides and may cause a shape change, discomfort, and may cause the breast to feel more firm. It may be more common following infection or hematoma.

    There are four grades of capsular contracture - Baker Grades I through IV:
    Grade I - the breast is normally soft and looks natural
    Grade II - the breast is more firm but looks normal
    Grade III - the breast is firm and looks abnormal 
    Grade IV - the breast is hard, quite often painful, and looks very abnormal

Example of breast implant capsular contracture Example of breast implant capsular contracture

Read more about capsular contracture

  • Dissatisfaction with the size of one's implants is the most common reason women have a second operation is to change the size of their implants (almost always switching to a larger implant). Dr. Revis spends a considerable amount of time with you discussing size, your expectations and your chest dimensions during your initial consultation and during your preoperative visit. Dissatisfaction with your implant size should be totally preventable by a thorough evaluation and decision-making process. 

Patient dissatisfied with breast implant size

Combination Problems

  • Double bubble occurs when there is a groove along the breast below the nipple giving the appearance of the breast sitting on top of the implant. This may represent a problem with the tissue characteristics as well as a problem with the surgical placement of the implants and may occur on one or both sides.

Double bubble breast implant deformity Double bubble breast implant deformity

  • Rippling is described as irregularities of the implant surface that can be felt or seen through the skin. This may result from thinning (atrophy) of the tissue covering the implants, a saline implant that is underfilled or leaking, a placement problem such as an implant being placed above the muscle, or some combination of these events.

 Example of breast implant rippling Example of breast implant rippling Example of breast implant rippling Example of breast implant rippling

  • Muscle flexion distortion occurs when the pectoralis muscle sticks to, or scars down to, the capsule surrounding the breast implant. When the chest muscle is flexed, it can lead to a distortion of the breast. This is a relatively rare occurrence noticed only during flexing of the pectoralis major muscles.

Double bubble breast implant deformity Double bubble breast implant deformity

  • Implant visibility, being able to see the outline of the implants through the skin, usually accompanies rippling and palpability. See rippling explanation above.
     
  • Implant palpability, being able to feel the implants beneath the skin, usually accompanies rippling and visibility. See rippling explanation above.

Solutions to Breast Augmentation Problems

Dr. Revis has developed a scientific approach to breast augmentation and the correction of breast augmentation problems. Depending on your specific problem, a specific solution exists. These may include:

  • Implant Exchange (replacing your present implants with new implants that may be smaller or larger, overfilling saline implants to reduce rippling, changing to a new implant shape such as High Profile, Smooth or Anatomical implants, changing the surface of the implants from smooth to textured or vice versa, or changing the filling of your implants from saline to silicone or vice versa)
  • Capsulectomy (removing the entire capsule surrounding the implant) is the definitive, state of the art treatment for capsular contracture. This may be combined with moving the implants into a totally submuscular position and/or switching to textured implants in an effort to reduce recurrence rates
  • Capsulotomy (making an incision in the capsule surrounding the implants) is not a successful method for treating capsular contracture but can be very useful when the implant pocket needs to be adjusted
  • Pocket Change (moving the implants from above the muscle to below the muscle can provide better soft tissue coverage of the implants, reducing a number of the potential complications described herein)
  • Mastopexy (breast lift surgery): There are different types of lifts depending on the amount of lifting and reshaping that is required. A crescent mastopexy (using an incision from 10 o'clock to 2 o'clock around the top of the areolar border) can raise the nipple 1-2 centimeters. A Binelli (aka donut or concentric) mastopexy (using an incision around the outer border of the areola can raise the nipple up to 4 centimeters), can raise the nipple 2-4 centimeters. A vertical mastopexy (creating a lollipop-shaped incision around the outer border of the areola and extending downwards towards the inframammary crease) can lift the nipple up to 6 centimeters. A full traditional mastopexy (creating an anchor-shaped or inverted-T shaped incision around the outer border of the areola and extending downwards to the inframammary crease and then medially and laterally along the inframammary crease) can lift the nipple 8 centimeters or more. Please read more about mastopexy on this website if you think you might be a candidate for this procedure. You will also find photographs of patient examples of several types of these lifts.
  • Internal pocket adjustment (for bottoming out or other position problems, described more thoroughly below)
  • Synmastia repair (repairing the connection of the overlying skin to the underlying breast bone or sternum)
  • Areolar reduction (using an incision placed around the outer border of the areola)
  • Correction of a "Snoopy" deformity (using an incision around the outer border of the areola
  • Correction of a tuberous breast deformity (using an incision around the outer border of the areola)
  • Correction of natural asymmetry (which may require implants of different sizes or shapes as well as adjustment of the inframammary crease on one or both sides)

The Internal Bra Technique

As a specific example of a problem requiring a thorough, systematic approach and innovative techniques demonstrated in photographs below, Dr. Revis has seen a dramatic increase in the number of patients presenting from other offices with bottoming out of one or both implants. This means that the pocket, or capsule, surrounding the implant has enlarged or stretched under the effects of gravity and have become too low on the chest wall or rests too far laterally when lying down. This may cause the appearance to be unattractive and even uncomfortable when wearing no bra. The implants may hang too low, preventing you from being comfortable when braless. You may also experience the implants falling far apart and even into the armpits when lying down. 

To correct bottoming out, Dr. Revis uses the Internal Bra technique. Using special lighted retractors, Dr. Revis expands the implant pockets (capsulotomy) superiorly and medially, creating room for the implants to be repositioned at a higher level- creating better cleavage, a more youthful shape, and improved fullness in the upper pole of the breast. After expanding the pockets in these directions, he then closes part of the pocket that rests laterally and inferiorly, thus preventing the implants from resting too low or falling too laterally to the sides. Dr. Revis uses permanent sutures for a long-lasting result. These sutures are carefully placed so that the suture material is never in direct contact with the implants inside the body.

Bottoming Out Correction: Before and After Photos Bottoming Out Correction: Before and After Photos
Before After
Photos show a 32 year old patient with bottoming out and a wide gap, at pre-op and six weeks post-op. An Internal Bra procedure was performed with implant exchange from 275cc moderate plus profile silicone gel to 325cc moderate plus profile silicone gel.

Types of Breast Implants

Silicone Gel vs. Saline Filled Breast Implants

There are two basic types of implants, silicone gel and saline filled. The new silicone gel implants arrive from the manufacturer already filled with cohesive silicone gel (not liquid silicone) in their sterile packaging. Saline implants arrive from the manufacturer empty, in sterile packaging, and are actually filled with sterile saline solution in the operating room.

After 15 years of intensive research, the new silicone gel implants were approved by the FDA in November 2006 and continue to be studied. To date, there have been numerous studies involving over one million women with the new silicone gel implants, and these studies clearly show no link between silicone gel implants and any type of disease.

During the 1992-2005 FDA study period of silicone gel implants, there were strict limitations on which women qualified to enter the FDA study protocol. Because of these limitations, the majority of women undergoing breast implant surgery chose saline implants. Now that the restrictions have been lifted and silicone gel implants are available to everyone, the numbers are much more equal in terms of what type of implant a woman chooses.

Silicone gel implants have an advantage in some patients because of their softer, more natural feel. In fact, many women who have saline or the older type of silicone implants are now having them replaced with the new silicone gel implants.  Saline implants have an advantage in some patients because they may be adjusted if your breasts are different sizes, they are less expensive than silicone implants, and they may be placed through a smaller incision.

There are several reasons a woman might choose one type of implant over another, and these include cost, body type, current breast size, and the desired look and feel after surgery. During your consultation, Dr. Revis will discuss with you which implant type might be the best choice for your individual needs.

Smooth vs. Textured Surface Breast Implants

Breast implants may have a smooth surface or may have a rough, textured surface. The textured implants were produced in the hopes that they would decrease the incidence of forming scar tissue around the implant, also known as a capsular contracture. This does appear to be effective in reducing the risk of developing a capsular contracture, but only when the implant is placed above the muscle of the chest wall (see Implant Placement Options, below). Textured implants have never been shown to provide any advantage over smooth implants when placed beneath the muscle of the chest wall.

Textured implants also have their own disadvantages. Textured implants are manufactured by taking a smooth implant shell and applying the texturing to the outer surface. This texturing process makes the shell slightly thicker and more stiff, which translates into an implant that is more visible through the skin and is more easily felt when the breast is touched (rippling).

Because of these disadvantages and because most implants are placed beneath the muscle, the great majority of breast implants used today are of the smooth variety. Dr. Revis believes that the smooth surfaced implants provide a much more natural look and feel when compared to textured implants. 

Round vs. Anatomically Shaped Breast Implants

Most breast implants used today are round. There are also implants which are teardrop shaped, called anatomical implants. These are in an attempt to better simulate the shape of the natural breast. In certain cases these may be recommended, but ALL anatomical implants are textured, with the accompanying disadvantages of textured implants. Please ask Dr. Revis if you think you might be a candidate for anatomical implants.

Moderate Profile vs. Moderate Plus Profile vs. High Profile Breast Implants

Both saline and silicone round breast implants are available in three different profiles — Moderate, Moderate Plus and High. Silicone implants also come in UltraHigh profile. The difference between these types is the diameter and projection. The traditional, or original, profile available was the Moderate. For any given size (cc’s), the Moderate profile implant will have the widest diameter and the least projection. The UltraHigh profile implant is the narrowest in diameter with the greatest projection. Moderate Plus profile and High Profile implants fall in between. We will discuss which implant type and style would best fit your needs during your consultation based on the measurements Dr. Revis takes of your chest, the review of pre- and postop photographs, and when you try on the implant sizers.

See detailed information about Allergan breast implants, Mentor breast implants and Sientra breast implants.

Incision Placement

The incision for breast augmentation may be placed underneath the breast, around the areola (the pigmented skin surrounding the nipple), in the armpit, or in the belly button. Dr. Revis performs all of these types of incisions, and he will discuss which might be the best for your specific situation at the time of your consultation.

Nationally as well as in Dr. Revis’ practice, most patients choose an incision around the nipple or in the crease underneath the breast. This provides the surgeon with the most precise control over implant placement, especially when your breasts differ in size or shape. When performed properly, an incision around the nipple or in the crease underneath the breast is minimally noticeable and should in no way prevent breastfeeding or alter nipple sensitivity.

Implant Placement

Subglandular vs. Partially Submuscular vs. Totally Submuscular Implant Placement

Breast implants may be placed beneath the tissue of the breast (subglandular), or may be placed even deeper, beneath the muscle of the chest wall (totally submuscular). There is also a subpectoral (or partially submuscular) placement that some surgeons use, meaning that the implant is placed beneath the pectoralis major muscle only, leaving the outer, lower 1/3 of the implant not covered by muscle tissue. The decision is a very individual one, and it is determined by the natural shape of your breasts and chest wall muscles.

 Implant placement in subglandular and submuscular augmentation
A cross-sectional diagram of subglandular (left)
and submuscular (right) augmentation

Whenever possible, Dr. Revis prefers to place the implants in a totally submuscular position. Dr. Revis believes that the advantages of placing the implants completely beneath the muscle of the chest wall greatly improve the long-term appearance of your breasts following augmentation. This is for three main reasons. First, mammography is easier and the quality is better when the breast implant is separated from the breast tissue by the layer of muscle. Secondly, there is a lower incidence of capsular contracture when the implants are placed totally beneath the muscle. Capsular contracture occurs when the body produces scar tissue around the implant. This may change the shape of the implant and make the breasts asymmetric. Finally, placing the implants beneath the muscle of the chest wall makes your breasts appear more natural because there is more of your own tissue covering the implant, making it less likely that you will be able to see or feel the implant.

Dr. Revis uses a special technique and instruments to place the implants 100% beneath the muscle of the chest wall without cutting any of the muscle tissue. This entirely submuscular placement will improve your long-term results and minimize your potential complications. It also yields little or no bruising post-operatively.

Choosing the Proper Implant Size

This is one of the most important decisions you will make. Because of this, we use several approaches to help you make the best decision based on your anatomy, personal preferences, and the appearance you wish to achieve. Interestingly, in a recent national survey, over 80% of patients undergoing breast augmentation stated that a "C" cup was their desired post-operative goal. A "D" cup was the second most popular request.

We begin by showing you numerous examples of patients who have had augmentation. By finding someone who has a similar preoperative appearance and evaluating their results with the size they chose, you can get an idea of whether or not you like the size they chose or if you would like to be smaller or larger than their final appearance. You may also wish to bring photographs from magazines or websites to better communicate with Dr. Revis regarding the exact size, shape and "look" you are trying to achieve.

Dr. Revis will also measure your natural breast and chest shape. This gives him an idea of what size implant will help you achieve the size you want post-operatively. As implant size increases, so does the diameter of the implant. There is an implant that will perfectly match the diameter of your natural breast, and that is a good starting point for discussion. Choosing an implant smaller than your natural breast shape will not provide the proper cleavage and shape following the procedure, and most commonly results in a large gap between the breasts. Similarly, choosing an implant too large for your natural chest shape is more likely to give you an unnatural appearance.

Unfortunately, implants do not come in cup sizes. Rather, they are categorized by the volume of filler (saline or silicone gel) they are designed to hold. There are several reasons for this. First, your final cup size will be partially determined by your preoperative breast size, and everyone is different in this regard. Secondly, a C cup from one bra manufacturer is not necessarily the same as a C cup from another manufacturer. Although everyone is built differently and bras are not manufactured to a set standard, you can expect that a cup size is approximately 200cc in a person of average height and average build. If you are tall or have broad shoulders, you can expect that number to be slightly higher. Similarly, if you are shorter or have a more narrow chest, you can expect that number to be slightly lower. Although a desire for a certain cup size is helpful to Dr. Revis in guiding you in the selection of the proper implants, it is more helpful to focus on the shape and appearance that you wish to achieve.

Finally, we will have you try on various implant sizers in a surgical bra. You may wish to bring a bathing suit, tank top or other clothing to see how you will look with different implant sizes. This helps confirm that you are making the right implant choice. We usually perform the trying on of breast implant sizers during the preoperative visit. This is because the initial consultation is very thorough, lasts approximately one hour, and tends to provide you with a tremendous amount of information to digest. In his experience, trying on implants at this point in the developing physician-patient relationship rarely leads to a conclusive decision and almost always needs to be repeated. However, we also understand that many patients travel a long distance for a consultation with Dr. Revis. With that in mind, we are willing to be as flexible as possible with out of town patients and allow the trying on of implant sizers during the initial consultation if we are given enough advance notice to schedule a more lengthy appointment. Also, please feel free to make as many trips to the office as you need to be satisfied with your implant selection. Our goal and the measure of our success is your happiness.

Using these three approaches, you will be able to accurately select the implant that will give you the appearance you desire. When asked about size post-operatively, over 95% of our patients feel they chose the right size implant to achieve the appearance they envisioned. The remaining few state that they might have gone larger if they were to choose again. We almost never hear that a patient wishes they had chosen a smaller implant. Therefore, if you are debating between two sizes, it is probably a better decision to opt for the larger size. 

Hopefully the above information has helped to clarify some of the issues surrounding breast augmentation. The following information will help prepare you for your procedure.

The Consultation

During your initial consultation, Dr. Revis will inquire about your medical history, prior procedures, medications, allergies, and your motivations for seeking plastic surgery. It is very important that you be thorough when providing your medical history, as this information helps to prevent complications during your care. When asked about medications, be sure to include any vitamin or herbal preparations, as these can affect your blood pressure and clotting ability. Honesty regarding your use of tobacco and alcohol is also very important, as these may have a profound impact on your recovery period and your ability to heal following your procedure.

After reviewing your medical history, Dr. Revis will discuss your concerns, priorities and motivations for pursuing plastic surgery, as well as your fears. After examining you, Dr. Revis will be able to offer advice and options to help you achieve the appearance you desire. He will explain the advantages and disadvantages of the different options you have before you. You will also be shown the different types of breast implants. 

At the completion of your consultation, you will be given a written estimate of the cost of your procedure. At this time, you will also have the option to schedule your procedure if you so choose. The decision to undergo surgery is a very important one, and the final decision should be given very careful consideration. Dr. Revis realizes the importance of this decision, and at no time will you be pressured to make a decision. You are also encouraged to bring your spouse, significant other, family member, or a friend to your consultation.

Breast implants come in many different types, and they may be placed through different incisions and in different locations. Once you have decided to undergo a revision of your augmentation, there are three main choices you must make — incision location (whether or not your prior incisions will allow the proper procedure to be performed or if you may need additional incisions), whether or not your implants will be replaced and if so then the new implant type and size, and whether or not the implant pockets will remain the same or be changed. This can be quite confusing, and the information presented here is to help you understand the various issues involved in making your decision.

Where Your Procedure Will Be Performed

Dr. Revis has been granted staff privileges at our local hospitals and outpatient surgery centers. In the interest of the safety of his patients, he only performs surgery in fully accredited facilities with the proper services and staff. Dr. Revis usually performs breast augmentation at Broward General Medical Center or Imperial Point Medical Center (both fully accredited hospitals) or the Imperial Point Surgery Center (a fully accredited ambulatory surgery center). The staff of these facilities are very experienced in the care of plastic surgery patients in general and specifically in the care of Dr. Revis’ patients.

Types of Anesthesia

Anesthesia is an essential part of any surgical procedure and must be performed safely. General anesthesia is the deepest form of anesthesia. You are asleep, feel no pain, and will not remember the procedure. This form of anesthesia is usually not required for breast augmentation unless the patient specifically requests general anesthesia.

Intravenous sedation, called twilight sleep, is a combination of local anesthetic administered at the surgical site by Dr. Revis and intravenous sedation administered by the anesthesiologist. You breathe for yourself, but you are in a deep sleep throughout the procedure. You should feel no pain, and you will not remember the procedure.

An intermediate form of anesthesia, the laryngeal mask airway (LMA), is a relatively new technique. This technique is similar to twilight sleep in that you are breathing on your own, but the method of sedation differs. With an LMA, you actually breathe anesthetic gases administered by the anesthesiologist, rather than receive intravenous sedation via your intravenous line. These anesthetic gases cause you to sleep during the procedure. At the completion of the procedure, the gases are turned off and you wake up from your sleep. You will feel no pain, and you will not remember the procedure. This is the most common type of anesthesia used by Dr. Revis because he feels that the effects of this type of anesthesia leave your body the fastest, allowing you to feel better faster with very little likelihood of post-operative nausea.

The prevention of post-operative nausea and vomiting is also a focus of Dr. Revis’ approach to breast augmentation. To improve your overall experience and ensure you feel better faster following your augmentation, he has developed a technique that has resulted in a very low incidence of post-operative nausea and vomiting. You will be given an intravenous dose of Zofran at the beginning of your operation. Zofran is a new drug which is currently the best medication available to prevent nausea and vomiting. Dr. Revis feels it is a very important component of his overall approach to make sure that your experience is as pleasant as possible.

Dr. Revis will discuss all of these options with you more thoroughly at the time of your consultation, and please ask him about anything you do not understand.

Details of the Procedure

Breast augmentation usually takes one to one and a half hours to perform. After you have changed into a gown and had your intravenous line started, you will be given a dose of intravenous antibiotics as a precautionary measure. Dr. Revis will use a surgical marking pen to identify certain landmarks on your chest. This ensures proper implant placement and symmetry post-operatively. He will also review the entire operative plan with you including incision location and implant type and size. 

After you are properly anesthetized in the operating room, Dr. Revis will inject a solution of local anesthetics along the borders of your breasts, underneath the intended incision site, and into the muscle under which the implants will be placed. This injection solution consists of a special combination of lidocaine (xylocaine), marcaine (sensorcaine, bupivicaine) and epinephrine. This accomplishes several objectives. First, the epinephrine causes vasoconstriction of the area, reducing your potential for bleeding and bruising. Secondly, the lidocaine provides a rapid numbing of the area. Although you are asleep, this prevents the brain from registering any pain from the region during the operation. Studies have shown that this preemptive analgesia actually decreases your sensation of pain post-operatively, decreases the amount and length of time you will need to take pain medication post-operatively, and also leads to a more rapid return to normal daily activities. Finally, the marcaine component of this local anesthetic mixture is a long-acting local anesthetic. This actually prolongs the numbness of the area, making you more comfortable following surgery and delaying the time at which you will begin to need any pain medications. 

Incisions and Pocket Creation

After allowing time for the local anesthetic mixture to take effect, Dr. Revis will make the incisions necessary for placement of the implants. Using the newest techniques and instruments, Dr. Revis is able to create a pocket beneath the muscle of the chest wall without cutting any of the muscle. This is extremely important for the maintenance of long-term results. 

Insertion and Filling of Saline Implants

Once the pockets have been created, the breast implants are inserted and filled with saline. Dr. Revis uses a no touch technique when placing the implants into the pocket. This includes using new sterile towels to drape around the breasts, changing his gloves and washing the outer surface of these new gloves in sterile saline, and only opening the sterile implant packaging immediately prior to insertion. Dr. Revis is the only person who ever touches the implants, and his goal is to minimize the time the implant is exposed to the air in the operating room prior to insertion into the pocket. Additionally, Dr. Revis does not allow the implant to come into contact with any instruments or the skin during the insertion process. He feels that this minimizes the possibility of any foreign material coming into contact with the implant and causing any inflammation.

During the filling process for saline implants, Dr. Revis uses a closed system to fill the implants with saline. This means that the saline that enters the implant is never at any time exposed to the air in the operating room. The saline flows from a sterile bag through a sterile tubing directly into the implant. Dr. Revis feels this additional precaution prevents any foreign material from inadvertently being injected inside the implant.

Insertion of Silicone Breast Implants

Dr. Revis will use the innovative Keller Funnel to place the silicone breast implants into the new pockets. The Keller Funnel employs the no-touch technique, reduces trauma to both the implant and patient tissues, and allows the use of smaller incisions. Read more about the Keller Funnel.

Keller Funnel™ Certification Seal of Approval

Dr. Revis is certified by Keller Medical and uses the Keller Funnel in every silicone breast implant procedure he performs, as part of his ongoing effort to continuously improve surgical results for his patients.

Suturing and Dressing

After the implants have been placed (and filled properly in the case of saline implants) and Dr. Revis has assessed your final shape and size, the incisions are carefully closed with absorbable sutures to minimize your scar. A sterile dressing is applied to the incisions, and a soft surgical bra is placed over your breasts. Dr. Revis uses a technique in which all of the sutures are placed beneath the skin and are absorbed by your body. Not having to undergo suture removal has improved patient comfort and satisfaction.

Products to Help You Heal

SinEcch Arnica Montana is a natural product from Sweden which has been shown in clinical studies to reduce post-operative bruising and swelling. Begun the evening prior to surgery, this product is continued for four days post-operatively.

Scarguard MD A combination of hydrocortisone, silicone and Vitamin E, this product is painted on your scars topically like nail polish beginning three weeks after surgery, and it helps your scars fade so that they fade as much as possible.

These products are available for purchase in our office. Please ask us about these products and others if you have any further questions about whether or not these would be beneficial for you during your healing period. 

After Your Procedure

Breast augmentation revisions are performed as an outpatient procedure. After recovering in the recovery room for approximately one hour, you will be able to go home in the company of a friend or family member. Dr. Revis will also give you his cell phone number so that you may reach him directly at any time with any questions you might have. 

When you wake up from your procedure, you will be in the recovery room and will be wearing a soft surgical bra or sports bra. You may remove this bra on the second day following surgery and begin showering daily. After showering, simply pat your incisions dry and replace your surgical bra or a sports bra. 

The antibiotics that were prescribed during your preoperative visit (usually Augmentin) should be taken twice daily beginning on the evening prior to surgery. Continue this medication for five days post-operatively or until it is gone. The pain medication prescribed by Dr. Revis during your preoperative visit (usually Lortab or Vicodin) should be taken fairly regularly, every four hours or so, during the first 24 hours (when you are not asleep, of course). Most patients find that they are able to transition to Tylenol after three or four days. It is not safe to drive a car within 24 hours of taking pain medication, as your reflexes and alertness may be altered. Dr. Revis may prescribe a muscle relaxant (usually Flexeril) for you if he suspects that your muscles may be tight and uncomfortable following surgery. If so, you may take one tablet every eight hours if needed for muscle tightness.

Alternatively, you may also be a candidate for a revolutionary new product for the management of post-operative pain, called the On-Q Post-Operative Pain Pump. Be sure to ask Dr. Revis about this during your consultation if you think you might be a good candidate for this system.

You should plan to take it easy following your surgery. No strenuous activities, heavy lifting (over 20 pounds), aerobic exercises, swimming, contact sports, tennis, or golf should be planned for the first three weeks. As Dr. Revis monitors your recovery, he will advise you when it is safe to resume specific activities. 

Unlike many surgeons, Dr. Revis does not feel that you must follow any specific regimen of straps, massaging, etc., following your augmentation. His philosophy is that the time to place the implants properly and precisely is in the operating room through careful technique and attention to detail. In his opinion, there is very little manipulation that straps or massaging will accomplish in the post-operative period to change the position or shape of an improperly or hastily placed implant. Dr. Revis will, however, occasionally recommend gentle massaging as a way to relax the muscle under which the implant is placed. In select patients, this can lead to a more rapid relaxing of the muscle and a softening of the breasts. Dr. Revis will instruct you during your post-operative visits in the proper technique of massaging the implants if he feels this would be of benefit to you.

The Results You Can Expect

You will notice an improvement in your breast shape and size immediately. You may experience tightness in your chest, but this rapidly resolves as the muscles relax. A very mild swelling usually takes several weeks to subside. You should be able to resume your normal daily activities the day after surgery, and you should be able to resume all of your physical activities (sports, aerobics, running, etc.) within three weeks of surgery.

Please see our Preoperative Instructions and Postoperative Instructions for additional information.

Breast Augmentation Revision Before & After Photos

What Patients Are Saying About Dr. Revis

"I like your approach to patient care. You have a technique that enhances breast augmentation and the final correction of synmastia and that is your Internal Bra. I have never seen such awesome results." – Catherine from Canada
"Wow, I'm beyond thrilled with my breast revision. You did a fantastic job!! I got your famous Internal Bra which ROCKS!!!!" – Rory from Georgia
"Competent, sensitive physicians like you are the prize of the medical profession." – Viva from Illinois
"I can't even begin to describe how grateful I am that I found such a qualified and knowledgeable plastic surgeon." – Christal from New York
"I LOVE MY BREASTS! Thank you, Dr. Revis. You gave me my womanhood back." – Angelina from New Jersey
"I am 1 month postop, and I am so happy with my results. Thank you so much!!" – Kelly from Florida
"Dr. Revis is a genuinely compassionate individual who truly cares about the well-being of others." – Susan from Florida
"I am excited about my surgery and would fly across the world to have it done under your care." – Kathleen from California
"You make this unfortunate revision process I am going through hopeful, comforting and supportive." – Michelle from Florida
"They are looking amazing!!! You performed a miracle on me!" – Lisa from Seattle
"I'm SO happy with my BA results! I feel more confident and good about myself and I love the way I look!" – Diane from Florida
"I'm less than a week out of surgery and already loving my results. I don't know what you did but I didn't need any pain meds after day 3!" – Hope from New York
"THANK YOU Dr. Revis. I will never go to another plastic surgeon again!" – Athena from Washington
"It was a pleasure meeting you, and I certainly understand why so many patients drive/fly to see you. You are a breath of fresh air." – Charlene from South Carolina
"You have done an amazing job on women from all around the world!" – Emily from Texas
"I cannot thank you enough for your time and talent!! You did an amazing job and my husband and I couldn't be happier." – Natalie from Texas
"I sent pictures over to my Mom last night and she was so happy for me! She was amazed by such nice natural work!! You really are THE BEST!" – Chelsea from Florida
"It's been 15 months since my surgery and I have to say I am over the moon with the results. The augmentation looks very natural and the recovery and healing process were so smooth and easy. I really feel very lucky to have found you!" – Angela from New York
"I LOVE MY NEW BOOBIES!! They look SO natural, even my family doctor couldn`t find where the incisions were. They look and feel amazing!" – Melanie from Canada
"Just wanted to tell you I how much I appreciate your kindness." – Christi from Florida

Please call (954) 630-2009 or email Dr. Revis for further information or to schedule your complimentary consultation. We are conveniently located to serve the entire South Florida community including Miami, Fort Lauderdale, Boca Raton, Palm Beach and beyond.

Email: DrDonRevis@hotmail.com

 

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