I have received an email from a patient that had a breast augmentation by another surgeon.  Unfortunately, she experienced symmastia, a condition where one or both implants is able to cross the middle of her chest.  She writes, “are you able to fix it?”

Symmastia can be a very challenging problem to fix.  There are a number of procedures that have been proposed to address it including suture techniques, using flaps or other materials, adjustable implants, implant free periods, and changes in the implant  pocket.   I have used several of these techniques to address this problem with success.  Now, I have something that I feel is more reliable to offer.  The technique was presented by Spear et al. and recommends creating a “Neosubpectoral” pocket if the implant is already in the subpectoral position.  This is a brilliant idea because it uses the patients own tissues to deal with the problem.  It creates a new space for the implant between the pectoralis muscle and the implant capsule.  In this way an appropriately sized pocket can be created that will resist malposition or recurrent symmastia.  It eliminates some of the uncertainty, unreliability, and the drawbacks of a simple change of the implant into the subglandular (in front of the muscle) position. 

Our websites www.beauty-surgeon.com and www.drmckane.com have additional information and before and after photographs of breast augmentation for review.  I invite you to schedule a consultation with me if you would like to learn more about symmastia or its correction.  Please feel free to contact our office at (713) 661-5255 if you have any questions.

-Brice W. McKane, M.D.

© 2009, Dr. McKane. All rights reserved.

Today in clinic I visited with a patient that had silicone implants placed 20 years ago.  She had been referred to me because she had undergone an MRI for an unrelated reason and her implants were noted to be ruptured on the study.  I recommended that she replace her implants.  She asked, “My breasts haven’t gotten any smaller.  Why do I need to replace my implants?”

Unlike saline implants which will deflate, silicone breast implants can rupture and a woman may remain completely asymptomatic and not be aware of it.  This is termed a “silent” rupture.   If this occurs, the silicone gel spills into the space around the implant that is contained by the scar that the body develops around the implant (capsule).  The problem with this is that at times the gel can then migrate from this space into the breast tissue.  Silicone migration can occur even further and reports have shown that it can reach the elbow region, shoulder, chest, abdomen, groin, and even the shins.  The migrated gel can cause inflammation that presents as nodules under the skin.  These nodules are called siliconomas.  Siliconomas can cause pain and at times may create a communication to the skin’s surface that will ulcer and then drain.  Migrated gel has also been reported to cause lymphadenopathy (inflammed lymph nodes), infection,  fibrosis, and skin retraction.  The management of this problem usually requires surgical excision.  Depending on the area involved and the amount of silicone to be removed this can be very difficult or disfiguring.  So to answer this patient’s question; replacement of leaking silicone implants should be performed to avoid these problems. 

Our websites www.beauty-surgeon.com and www.drmckane.com have additional information and before and after photographs of silicone breast augmentation  for review.  I invite you to schedule a consultation with me if you would like to learn more about silicone breast augmentation or silicone migration.  Please feel free to contact our office at (713) 661-5255 if you have any questions.

-Brice W. McKane, M.D.

© 2009, Dr. McKane. All rights reserved.

Today in clinic, I had a patient who was an aerobics instructor ask,”Can putting the implant behind the muscle cause distortion of my breast during exercise?”  The answer to her question is yes, but I want to qualify this answer.

 In patients where implants are positioned behind the pectoralis muscle, contraction of the muscle can change  the shape of the breast.  This distortion in shape is called an animation deformity and is graded on a scale ranging from no deformity to severe.   It is something that occurs during contraction of the muscle and then resolves with relaxation.    A recent study by Spear et al. looked at this issue and reported that muscle related distortion was not a problem during  normal activities of daily living.  In this patient cohort, interference occurred during weight training, exercise, yoga, and sexual activity.  Interestingly, only 3% of patients reporting this problem would not consider subpectoral placement again.  It is apparent that these patients accept animation deformity in return for improved breast cancer detection, less risk of capsular contracture, less problems with visible rippling, and a better chest/breast/implant interface.  Although there are several techniques designed to help with this problem, the only definitive solution is to replace the implants into the subglandular (in front of the muscle) position.  However, this is at the expense of increased risk of capsular contracture, implant visibility and rippling problems, and greater difficulty with mammography.

Our websites, www.beauty-surgeon.com and www.drmckane.com have additional information and before and after photographs of breast augmentation for review.  I invite you to schedule a consultation with me if you would like to learn more about breast augmentation or animation deformity.   Please feel free to contact our office at (713) 661-5255 if you have any questions.

-Brice W. McKane, M.D.

© 2009, Dr. McKane. All rights reserved.

I received an email the other day from a woman who had visited another surgeon regarding breast augmentation.  During her consultation he told her that he routinely uses drains during the procedure.  She wanted to know if I also use drains during breast augmentation. 

For those of you who may not understand what a drain is,  let me get this out of the way first.  A drain is a small tube that is placed into a space within your body that is designed to pull fluid away from this space and usually into a collection device.  By their nature there is a path through the skin that the drain will cross.  Drains are used frequently during any procedure that is prone to develop a fluid collection or “seroma.”  A common procedure within Plastic Surgery that usually requires drains would be an abdominoplasty where a large space is developed beneath the skin.  Here is a picture of a drain:

To answer her question about whether or not I use drains, the answer is:  Almost never during a primary breast augmentation.  There are few instances when I would consider one and this is usually during a revision case when extensive work is performed on a breast capsule.  The reason that I don’t use them is that I believe that they are not necessary and it has been  well demonstrated that drains increase the risk of surgery requiring complications and significant capsular contracture in patients who have them. 

Our websites www.beauty-surgeon.com and www.drmckane.com have additional information and before and after photographs of breast augmentation for review.  I invite you to schedule a consultation with me if you would like to learn more about breast augmentation or the use of drains during a procedure.  Please feel free to contact our office at (713) 661-5255 if you have any questions.

-Brice W. McKane, M.D.

© 2009, Dr. McKane. All rights reserved.

A patient in my clinic today asked an insightful question that I would like to share with you.  She noted that she understood that there is evidence supporting that there is a decreased risk of capsular contracture after breast augmentation if the implant is positioned behind the muscle.  She wondered, “Is there  an incision that is associated with less risk for capsular contracture ?”

A prospective study by Henriksen et al.  answered this very question.  The authors looked at the causative factors surrounding surgery requiring complications and significant capsular contracture in 2277 women undergoing breast augmentation.  The authors found that the “inframammary” or breast fold incision was associated with the least risk for complications requiring surgical intervention. Patients who elected to have this incision also experienced less risk of capsular contracture.  In fact, patients opting for periareolar or any other incision were 5.8 times more likely to develop capsular contracture than those who had inframammary incisions.  This evidence has led me to counsel my patients to strongly consider the inframammary incision for their approach to a breast augmentation.   

Here are the pre and postoperative photographs of a breast augmentation done through an inframammary incision.  This patient is very thin and had very little breast tissue.   Even in this patient, the incision is very well concealed and is barely visible on front view.  

Pre and Postoperative views

The postoperative photograph is taken at 1 month following surgery to show what an immature incision may look like when it is the most visible.  The incision will continue to fade with time.  This small investment in an easily concealable incision can have a significant impact on the need for additional surgery.

Our websites www.beauty-surgeon.com and www.drmckane.com have additional information and before and after photographs of breast augmentation for review.  I invite you to schedule a consultation with me if you would like to learn more about breast augmentation or the incisions involved in this procedure.  Please feel free to contact our office at (713) 661-5255 if you have any questions.

-Brice W. McKane, M.D.

© 2009, Dr. McKane. All rights reserved.

I received an email over the weekend from a woman that has undergone a breast augmentation approximately 5 months ago by another surgeon.  She noted that her implants were placed through the axillary (arm pit) approach and that her implants have fallen too low on her chest.  She writes, “My breast implants have dropped, what can I do?”

Implant malposition following breast augmentation is probably a more frequent problem than is identified in the literature.  It can be seen with any of the surgical approaches.  Malposition can be due to a technical error or it can be the result of the weight of an implant and it’s effect of stretching or dissecting the breast tissues.  It is clear that larger implants are more prone to malposition than smaller ones.  We would describe this woman’s problem with implants that are too low as “bottoming out.”  Malposition can occur in any direction, that is, implants can be positioned too high, too low, too far towards the center of the chest, or to far towards the arm.  

If conservative measures fail to improve implant malposition, there are several surgical techniques that can be used to correct the problem.  These involve using suture lines to close down a portion of the implant pocket and correct the implant’s malposition.  In the technique that I use, I also perform capsulotomies (incisions in the breast capsule) opposite the location of the suture lines  to take some of the tension off of the repair.  Patients are required to tape the breasts and to wear underwire bras for several weeks after surgery to support the repairs while they are healing. 

Here is an example of a patient that experienced implant malposition following a transaxillary breast augmentation.  She was an A cup before her initial procedure and had very short nipple to inframammary fold distances.  She had selected a sizable implant for her initial procedure.  If you consider the history of this patient, she was a set up for problems with implant malposition.  When she presented to my clinic she had “bottoming out” of her implants; that is, they were positioned too low on her chest wall.  Here is the preoperative photograph:

During our consultation she expressed a desire to use the same size implants as her initial surgery.  Her goal was to correct the low position of the implants on her chest.  I performed capsulorraphies (suture closure of the breast pocket) at the lower aspect of the breast on both sides to reconstruct the breast fold and move the implants to a higher position on the chest.  During the procedure I also performed capsulotomies opposite the suture lines at the upper aspect of the breast to take some of the tension off of the repair.  Here is the postoperative result:

The operation achieved her goal of correcting the low position of her implants through reconstructing the breast folds on both sides.  She is now very pleased with her results. 

Our websites www.beauty-surgeon.com and www.drmckane.com have additional information and before and after photographs of breast augmentation for review.  I invite you to schedule a consultation with me if you would like to learn more about breast augmentation or reconstructing implant malposition.  Please feel free to contact our office at (713) 661-5255 if you have any questions.

-Brice W. McKane, M.D.

© 2008 – 2009, Dr. McKane. All rights reserved.

I am writing today to talk about a problem that I see frequently in my clinics.  As a board certified Plastic Surgeon it is my obligation to inform my patients to the best of my ability about the procedures that they are considering.  Ethically, I am unwilling to minimize or to ignore the risks associated with the surgeries during my discussions with my patients.  This discussion is a vital component to an informed decision. 

Unfortunately, this doesn’t seem to be the case for all surgeons.  I see a fair number of revision breast augmentation cases in my practice and very frequently I hear, “I thought my breast implants would last forever! My surgeon never told me that I would need another operation!”  This misconception about the “immortality” or implants can be perpetuated by misleading information found on the internet or in advertising, or through the anecdotal experience of a patient’s friend who had undergone the procedure before her. 

I am here to set the story straight.  Implants do not last forever and there can be problems with them.  Unfortunately, the fact of the matter is, many women who undergo a breast augmentation will need a secondary procedure in the future to address some issue with their implants. 

Rupture of either a saline or a silicone implant may occur at some point in time following a breast augmentation.  Removal of the implant is recommended following a rupture, and this is particularly true of silicone implants.  The reason for removal is that the silicone gel can escape from the implant and implant capsule and penetrate into the breast tissue.  Gel that has migrated into the breast tissue may require removal of some of the breast tissue to fully address.  Replacement of implants is common following rupture as many women are unwilling to return to a smaller breast size . 

The development of capsular contracture is another problem that can occur with time.  As this develops, the breasts can become firm, change shape and even become painful.  Significant capsular contracture is another reason that a woman may consider a reoperative procedure following her breast augmentation.  This may prompt you to ask, ”If you have surgery to address capsular contracture, it won’t come back. Right?” Unfortunately, that’s not the case and the risk of recurrent capsular contracture is higher following the secondary surgery.  Furthermore, reoperative procedures do not reduce the risk of needing future surgeries for other reasons. 

Here is an example of patient that underwent a saline breast augmentation 13 years ago.  She presented to my clinic with a complaint that “I woke up this morning and my implant had ruptured.”  She wanted to replace her implants with new implants of similar volume.  On examination there was marked asymmetry of her breasts and she had a ruptured left saline implant.  The right breast had a very mild capsular contracture.  There was a nearly imperceptible inframammary (breast fold) scar.  Here is the preoperative photograph:

During our consultation I spoke with her about removing and replacing her implants into the dual plane.  I performed capsulotomies (incisions in the capsule) on both sides to help open the scar and allow it to remain soft.  I did not remove the capsules on either side because they were mild.  The patient’s original implant volume was not known until the time of surgery as there was no record of her procedure available.  She decided that she would like to use a 325 cc size and this is what I used for her.  The original implant volume turned out to be 300 cc’s.  Here is the postoperative result at 3 months:

This patient was very satisfied with her saline implants and wanted to remain augmented following her rupture.  She was unprepared to return to her pre-augmentation size as she felt more proportional with her implants.  The operation that I performed achieved her goal of restoring the volume lost when her implant ruptured. 

Our websites, www.beauty-surgeon.com and www.drmckane.com have  additional information and before and after photographs of breast augmentation for review.  I invite you to schedule a consultation with me if you would like to learn more about breast augmentation or reoperative surgeries.  Please feel free to contact our office at (713) 661-5255 if you have any questions about this procedure.

-Brice W. McKane, M.D.

© 2008 – 2009, Dr. McKane. All rights reserved.

As a board certified Plastic Surgeon that specializes in breast and body contouring I am often asked for advice about problems associated with cosmetic surgery.  I  received an email yesterday asking for help with breasts that have become firm and hard following breast augmentation surgery.  I’d like to comment on this here to provide other women with this common problem an avenue to find out additional information that may help them. 

The most likely diagnosis for firm breasts following breast implants is capsular contracture.  An implant capsule is a scar that forms around the implant on the inside of the breast.  Capsules develop in all women who have undergone breast augmentation.  In and of themselves,  capsules are not a problem.  The problem begins as the scar begins to shorten or contract around the implant.  In milder forms this squeezing on the implant causes breast firmness.  Unfortunately, the problem can be progressive causing very hard breasts, change in the shape of the breast,  or even pain in the breast.  In a recent study by Allergan, an implant manufacturer, the risk of developing significant capsular contracture after silicone breast augmentation is 14.8% at 6 years. 

Capsular contracture, at least in theory,  is reduced when implants are positioned behind the pectoralis muscle, when implants are massaged daily to stretch the implant capsules, and by the use of textured implants.  That being said, capsules can still develop even when all of these options are exercised.  Some patients may have a predisposition to developing exuberant scars.  Others may develop a collection of blood around their implants (hematoma) or an infection that can contribute to the development of the problem. 

There is research being conducted into the use of medications to prevent and treat capsular contracture.  Accolate(Zafirlukast) a leukotriene antagonist used initially for reactive airway disease showed promising results in reducing breast firmness over a 6 month treatment course.  More recently, Pirfenidone, an antifibrotic medication prevented the development of capsular contracture in an animal model.  Both of these medications will need additional study before being used widely in the treatment of capsular contracture.

The mainstay of treatment at this point for capsular contracture is surgery.  Implant capsules can be opened up in a procedure called capsulotomy, or they can be removed in a procedure called capsulectomy.  Implants are typically  exchanged at that time.  Some women may elect to have their implants removed and not replaced.  If this is the case, additional breast contouring procedures such as breast lift (mastopexy) may be necessary.   

I have included a case presentation that demonstrates the typical findings of this problem.  She is a 49 y/o woman who underwent a subglandular silicone breast augmentation in 1988.  Over time, her breasts have become ”rock hard” and are now causing her pain.  These are the preoperative views of the patient showing distortion of the breast and firmness in the upper portions on both sides.  Examination of the breast demonstrated extremely firm breasts with probable calcification of her capsules.  Here is the preoperative view:

The patient underwent a procedure where her breast capsules were opened (capsulotomies) and removed (capsulectomies) to restore softness to the breast.  New implants were positioned into the Dual Plane to reduce the risk of recurrence of her capsular contractures.  We spoke about performing a breast lift for her but she declined and was only interested in addressing her implant capsules.  These are the postoperative views at 6 months:

The surgery achieved her goals of a much improved and natural slope of the upper portion of the breasts.  The breasts are completely soft and no capsule is palpable by examination.   

Our websites www.beauty-surgeon.com and www.drmckane.com have additional information and before and after photographs for review.  I invite you to schedule a consultation with me if you are experiencing this problem and are looking to learn more about this common problem.  Please feel free to contact our office at (713) 661-5255 if you have any questions. 

-Brice W. McKane, M.D.

© 2008 – 2009, Dr. McKane. All rights reserved.