Peer to Peer
Patients can present with a number of problems owing to previous breast surgery, whether augmentation or reduction.
Mr Shailesh Vadodaria presents a myriad of examples for our panel to discuss the treatments they would recommend
Mr Shailesh Vadodaria is a consultant plastic surgeon who is on the specialist register of the GMC;
Dr Dennis Hurwitz is a cosmetic surgeon and is director of the Hurwitz Center for Plastic Surgery in Pennsylvania, USA;
Dr Luiz Toledo is a consultant plastic surgeon, originally from Brazil, now practicing in Dubai;
Dr Riccardo Frati is a plastic surgeon who recieved his clinical fellowship in cosmetic surgery with Prof Gaspatotti;
Mr Basim Matti is a consultant plastic surgeon, a member of BAAPS and is the UK secretary for ISAPS;
Mr Barry Jones is a consultant plastic surgeon, craniofacial surgeon and past president of BAAPS;
Mr Raj Ragoowansi is a consultant plastic, reconstructive and aesthetic surgeon practising in London;
Mr Nick Percival is a consultant plastic and cosmetic surgeon with a special interest in aesthetic breast surgery;
Mr Alex Karidis is a consultant plastic surgeon who runs his own private practice in central London;
Mr Andy Batchelor is a consultant plastic surgeon and is a member of BAPRAS and BAAPS;
and Mr Shiva Singh is a plastic surgeon based in central London, with a special interest in aesthetic breast surgery.
Issue 1: Size dissatisfaction following bilateral breast reduction
Mr Shailesh Vadodaria: The first case is that of a 66-year-old patient who had received a badly done liposuction elsewhere and requested a bilateral breast reduction. We performed the surgery and, six weeks down the line, she complained the size was too small and that she would like a breast augmentation. I advised her I would not carry out any further surgery for one year, for maturation of scar and then we could revisit the situation. A year has now passed, how would you now manage this patient? Firstly as a patient—not relating to technique—and second, following mutual agreement with the patient and if anything needs to be done, what would you do?
Dr Dennis Hurwitz: With a patient who has a larger body type, it can be difficult to get small enough breasts that are comfortable and don’t hang. For minor issues, I have sometimes used lipo-augmentation to fill out the upper breast. Many people are rightly concerned about putting an implant in and getting sagging, so I’ve treated some patients with 200cc of fat as a reasonable and low cost alternative.
Dr Luiz Toledo: I had a case with a similar patient. She had an abdominoplasty and breast lift. She didn’t want smaller breasts but wanted them lifted because she had had four children. The first thing she said when she came to the consultation was “I’m a very difficult patient.” I told her exactly what I could do, and insisted on taking preoperative pictures. During the operative procedure—predicting potential difficulties in future—I took full photographs of the procedure. Then, post-operatively, I took pictures of the skin excess that I had removed from the breasts, without any gland in it, and a picture of the patient on the table immediately after the procedure.
At the one month follow up, she said her breasts were too small and wanted them back to the size they were. I was able to produce the pictures demonstrating that no breast tissue had been removed. She decided she did not want to increase breast size, but if she had, I would probably have put in an implant. As it was, I insisted she sign an agreement to state she would no longer be my patient and there could be no complaint in future.
Dr Riccardo Frati: Scientifically speaking, I would use a fat graft because this would enable me to correct the asymmetry. The patient would also feel that the lost volume was being replaced with something from her own body. But, hearing the background of this patient, I think the percentage of her being satisfied is too low, and I would therefore not operate further on her.
Mr Basim Matti: Every patient who comes to me must pay two weeks before any procedure. If the patient pays for the treatment, in general they’ll be very happy. But if they haven’t paid, there is always a reason for them not to. I refuse to operate if they have not paid one week before—this seems to settle the issue. If I had to operate again on this patient, I would first ask her to see a colleague of mine to get another opinion. I would pay for the consultation and then would agree that if I had to operate further, it would be an implant. However, I would be very careful with a patient like this.
Mr Shailesh Vadodaria: As Basim suggested, I would ask a colleague to give a second opinion and pay the fee. I would also give the patient copies of her notes, and write a detailed letter to her GP and send a copy to the patient.
Issue 2: A young female patient requesting correction of pectus excavatum and mastopexy following implant-based breast augmentation performed in the past elsewhere
Mr Shailesh Vadodaria: The next patient is a 21-year-old lady, who had a pectus excavatum and breast implants in the past. She now wants a mastopexy. There are two problems. One is correction of the skeletal deformity on the sternum. Another is the issue of mastopexy—would you perform this simultaneously? What would you do about the pectus excavatum?
Dr Luiz Toledo: Fat grafting would be a good solution for the pectus excavatum and this could probably be done simultaneously with a mastopexy.
Dr Dennis Hurwitz: I’ve been pleased with the results from fat grafting for moderate to mild deformities. But you would probably need a couple of treatment sessions and the patient should be made aware of that. As Luiz says, do a mastopexy. I am getting more wise in warning patients about potential drops of their breasts. I would probably ‘two-stage’ her—I don’t know how big the implants are, but I would remove them and put a small implant in a year later.
Mr Basim Matti: I have problems with this kind of pectus excavatum, especially with asymmetry. I had a patient who had an implant in front of the muscle, so one side of the chest was more vertical, while the other was more horizontal. After a year, the patient became upset because the implant slid on the vertical side. I had to operate on her and learned that you have to build behind the muscle as it acts as a barrier for the implant to slide down. In my experience with this kind of pectus excavatum, I would not treat the patient immediately as they are. I would do the mastopexy first and the implant later on. I would not use fat first as I don’t think the patient would be happy.
Mr Barry Jones: One of the most important things here is to manage expectations. If you talk to the patient about open chest surgery, she’ll almost certainly say no. In this case, you could explain how fat grafting could be used but the disadvantages are X, Y and Z. If the patient has reasonable expectations of what can be achieved—which is actually not a very good outcome however clever you are—then you’re fine. But you should at least ask or give the patient opportunity to discuss it with a chest doctor.
Mr Shailesh Vadodaria: In this case, we actually performed an autologous fat transfer in two stages and she was happy with the result.
Mr Barry Jones: Dennis, if you were to forget about the pectus and do a mastopexy on this patient—particularly looking at the left side—what kind of mastopexy technique would you use?
Dr Dennis Hurwitz: I’m not sure what proportion of this patient’s breast is implant, but assuming it’s a third, we have something to work with. If there is some bulk, it would be similar to a Pitanguy vertical technique—with the inferior flap continuing from the aureole down, as a de-epithelised enhancer, sutured up to the chest wall and the two pillars come from side to side. Owing to the suturing to the chest wall, there would be no room for an implant, nor do I want that dynamic in such a patient.
But I think that inferior pull could be readily used and pushed up—it looks like the whole footprint of that breast is too low. I could even use a Wise pattern technique and suture the T-portion up to the second rib as a double suspension. She should be informed about the inverted T keyhole pattern and resulting scars—you’re going to need a tremendous amount of skin and reshaping.
Mr Shailesh Vadodaria: In the end, I performed a two-stage autologous fat transfer and she is at present quite happy with the results. But if we were planning to do any kind of mastopexy, would you use the de-epithelised skin, based on intercostal perforator to augment the concavity of the pectus excavatum by inserting the soft tissue into the subcutaneous pocket?
Mr Raj Ragoowansi: The lateral pedicle can be de-epithelialised and raised. You don’t have to see the perforator, you can raise it as a wide-based pedicle. This can then be carried over and inset into the medial pole and even into the pectus excavatum so that you are dividing the pectum deformity in half. On the right side, one half of the pectum is being filled by the right lateral pedicle distal portion and then the left side in a similar manner. I think strategic use of pedicles with whatever breast tissue remains is a good option. I probably perform this as a two-stage procedure—the mastopexy first and then an implant if needed.
Dr Riccardo Frati: Principally it is a good idea but in this case you are at risk of having the aureole too high up. The flap would never get to the midline. Otherwise you would have the aureole too medially with your flap.
Issue 3: A patient in her late 60s requesting larger implants, following augmentation performed 40 years ago
Mr Shailesh Vadodaria: The next case is that of a 67-year old patient who has had implants for 40 years and would like replacements with larger implants. She explained she had bad capsular contracture, which she would like managed at the same time. The patient had significant tethering—how would you manage this before taking the patient to theatre? She also has a calcified capsule on the right side with a ruptured implant—how would you treat this?
Mr Barry Jones: Firstly, would you do any investigations before operating on her?
Dr Dennis Hurwitz: The patient would need an ultrasound or even an MRI. You want as much information as you can get in a patient of this age—there could be a ductal carcinoma.
Dr Luiz Toledo: I would do an MRI. As she wants bigger breasts, the solution will be easier than if she wanted smaller breasts. If she wants only one size bigger, then we would have to deal with scars.
Mr Basim Matti: If there is calcification behind the nipple, I would do nothing apart from exploring that calcification to see if it is cancer. That’s number one. If the implant has been calcified for many years, it could be that the implant is stuck to the nipple and is pulling it down. I would not operate until I had explored what the calcification is, ensuring it’s not cancer. I would do an MRI scan and then refer the patient to a general breast surgeon as I would not be happy to operate.
Dr Riccardo Frati: I would first get her examined by a breast surgeon, by MRI or ultrasound. Was the implant sub-muscular or sub-glandular?
Mr Shailesh Vadodaria: Sub-glandular.
Dr Riccardo Frati: She would therefore have little glandular tissue. You would therefore have a problem with the protection, or cover. After excluding any malignancy, I would perform a capsulectomy and put the implant under the muscles to provide some cover.
Dr Dennis Hurwitz: Patients want a simple, easy solution, such as just changing the implant. But there may be capsule contracture, rippling or worse, so there is no simple solution. This would be like a breast reconstruction case. Patients have incredibly high expectations which you have to manage because you can’t offer a simple operation.
Issue 4: Painful capsular contracture in the right breast following breast augmentation four years ago
Mr Shailesh Vadodaria: The next case is that of a 27-year-old woman. I performed a bilateral breast augmentation four years ago and she returned with capsular contracture on the right side. Now she has pain in her right breast and would like revisional surgery. She has also asked if I could upgrade the implant size. This patient had a dual plane augmentation with a round implant, and we also have to tackle the capsule contracture. Would you perform a capsulectomy? Would you change the plane? And if the patient requests a bigger implant, what size and shape would you recommend?
Mr Basim Matti: This is a very difficult case. If she wants too large an implant, I would send her to a specialist. Otherwise I would use a polyurethane implant behind the muscle and increase the size using a conical implant.
Mr Shailesh Vadodaria: Would you perform a capsulectomy?
Mr Basim Matti: It depends on the thinness of the skin. I would make the decision during the procedure. There are purists who would say remove the capsule, but you must consider the circulation of the skin. If the circulation is good and the tissue thickness is very thin, I would remove the capsule. If I am not able to do that, I would excise the capsule. If I was in a difficult situation, I would leave the capsule—the circulation of the patient is most important to me.
Mr Nick Percival: If you’re going to put in a polyurethane implant, you have to remove the capsule. This would be a silicone implant covered in polyurethane foam. If you want to get the beneficial effect of not getting capsular contracture, then you must remove the capsule. I don’t see a problem with removing the capsule because this is a sub-muscular implant.
Mr Alex Karidis: I would create a new pectoral pocket, which reflects the anterior portion of the capsule back so you don’t have to touch the one on the base of the ribs. You’re creating a fresh pocket that accommodates your polyurethane implant. It doesn’t matter if you leave the posterior aspect of the capsule. I would use an extra high profile because she has quite a narrow base if she wanted bigger breasts. I don’t have any issues with the viability there.
Mr Barry Jones: So this seems like a good indication for polyurethane.
Dr Dennis Hurwitz: Polyurethane implants are not available in the US so we would probably use Stratos implants. There seems to be some impediment to recurring capsule contracture.
Mr Nick Percival: I only use polyurethane implants for difficult cases with recurrent capsular contraction. I don’t use them all the time as, from a technical point of view, they are more difficult to use than pure silicone implants. They’re unforgiving in terms of position and most surgeons find, when they start using them, they tend to place the implant slightly too high and they don’t shift. I’ve also got one or two concerns about their shape. I find they tend to be rather broad and flat in comparison with the Nagor silicone implants that I normally use. However, we should start thinking about using conical shaped implants because these seem to avoid many of these problems.
Dr Dennis Hurwitz: Twenty years ago, we were using MEME and Replicon implants. Within seven or ten years, capsular contracture occasionally occurred and when patients came back, there was no polyurethane left around the implant and sometimes even a little seroma. That put me off somewhat. I take it this has not been the experience here?
Mr Nick Percival: The polyurethane foam and silicone implant detach from each other so you can then, if needed, perform revisional surgery. I don’t know if there’s a long-term problem with seroma formation in these implants. I’m not aware that this is an issue, but the polyurethane foam does detach from the implant. So after six months you’re technically left with a silicone implant. You do have a capsule around it but it seems not to contract in the same way that the capsule does from a normal silicone implant.
If you need to carry out revision surgery with polyurethane implants, you must wait some time because the implant is stuck to the foam coating. It takes three to four months for separation to occur. If you try and remove the implant following malpositioning, the best option is to take the patient straight back to theatre in the first week or so. Once that foam is incorporated, it is difficult to remove. But once the silicone has separated from the polyurethane, it’s pretty straightforward to take the implant out.
Mr Alex Karidis: I recently removed a polyurethane implant from a patient who I had put the implants in two years ago. She was perfectly happy with them in terms of encapsulation—there weren’t any grade one capsules—but she wanted to be bigger. I went in through the same incision and the foam covering was intact. It came off the capsule easily but what I was left with was a very thick capsule, albeit not contracted.
Normally when you exchange an implant, you find a very thin capsule, perform a capsulotomy and insert a bigger implant. To get the effects of a polyurethane implant re-established, you have to go back and take out the old capsule. Effectively I had a bigger operation on my hands—if I have patients coming in for bigger implants, I have to have to take out the capsule entirely again, creating a bigger operation for myself.
Mr Barry Jones: One of the interesting things about the PIP implants—not that I’ve ever used them, but I have taken some out—is that there is no capsule. There is free silicone around the implant but there is no capsule.
Mr Shailesh Vadodaria: There is an increasing trend of using polyurethane implants. Is there any evidence that if you use a polyurethane implant it has a better outcome with less capsular contracture compared to other textured implants for primary breast augmentations?
Personally speaking, whenever I have to remove a polyurethane implant with capsular contracture, it’s a nightmare. The capsule is thick and virtually stuck to the skin—it’s then very likely it could damage the skin.
Dr Dennis Hurwitz: I also don’t routinely use polyurethane implants. When I first heard about them, they were sold as a good implant that wouldn’t cause capsular contracture. Frankly, I don’t have a major issue with capsular contracture, so why would I want to introduce a new element into my practice, something that could have problems later on? Perhaps capsular contracture has been overstated to make the polyurethane implants seem better. I would, however, use them in the handful of patients who come back to my practice with recurrent contracture.
Mr Shailesh Vadodaria: I think we are creating two issues by introducing polyurethane implants without evidence. Firstly, they increase the chance of asymmetry because of malposition and secondly, if revision surgery is required, it would be difficult.
Mr Barry Jones: The problem is that there are no proper controlled trials going on in Europe, and there should be. Then we can maybe answer those questions.
Issue 5: Thoughts on ethics and risk factors when taking on post-operative care of patients who have had operations abroad—what should the upper size or volume limit be of implants?
Mr Shailesh Vadodaria: Consider, for example, a patient who had received very large implants for bilateral breast augmentation in the US—no UK surgeon was prepared to perform the procedure with large volume implants. Surgery has been performed through a sub-areola approach, sub-muscular or possibly a dual plane. Would you take this patient on for minor issues with wound healing? And what is the general thought process about implant size, what should the upper size limit be?
Mr Basim Matti: Firstly, I would take care of the wound and give her antibiotics. I wouldn’t have done that operation myself.
Mr Barry Jones: The problem is that once she becomes your patient, she becomes your problem. If you treat her, she then becomes your duty of care.
Mr Andy Batchelor: In the UK, the framework is simple. If you don’t do it with the consent, assent and cooperation of the general practitioner, then you look after that patient’s total care until the clinical episode is finished to her satisfaction. You are responsible for all her general medicine. What you should do is smile graciously and explain that the problem is outside your experience and she deserves treatment from a specialist.
Mr Barry Jones: I would agree—tell the patient, “This is out of my field of expertise and there’s no charge.”
Mr Basim Matti: If the patient has a good aesthetic result, but does have a wound problem, this should be treated on a humanitarian basis. However, I’m wiser after what I have heard.
Dr Riccardo Frati: Direct treatment is a very important issue. I would send her to her GP to take care of this as it is a general problem. Regarding size, I think it’s deplorable that there are no limits for implant size. It’s not a good argument to say if I don’t do it then someone else will.
Mr Shiva Singh: The maximum volume available in the UK is 1500cc and that would be a customised implant. Up to 800cc is available off the shelf. There are a small number of patients who want these implants—some are models, some have psychological issues.
I recently had 10 or 12 patients from across Europe who were mature, married women. Many of these patients already had 600cc implants but wanted bigger. I don’t feel that I’m causing any future problems by offering bigger implants apart from the effect of gravity, which is explained to the patient. I do not yet have a long-term follow up which I can quote, but in the first two years I have never had any problems with a larger implant.
Dr Luiz Toledo: The biggest implant I have put in was for an American patient. She was in the entertainment business and already had a 600cc implant. After five years, the implanted breast started dropping and she wanted to make them bigger. I used a 700cc implant—which, at the time, was custom made—and she was very happy. So 700cc would be my limit.
Diana Talaue: We need to respect what we personally consider to be beauty. I have few patients working in the entertainment industry but to me, excessive breast size means that the person is not satisfied with themselves. They want to be outside the normality of beautiful results and I would probably decline the patient.
Dr Dennis Hurwitz: In the US, you can’t get an implant larger than 800cc or custom made implant, so this patient probably had an over-expanded saline implant. I have seen patients who have sagging from 700cc implants and want 1,200cc and I have performed the surgery. They’re usually pleased and there are no problems.
Issue 6: How do we determine the volume of breast implants—patient choice, surgeon choice, sizers or 3D imaging?
Mr Shailesh Vadodaria: Finally, two questions. Firstly, how would you determine with the patient the size and shape of the implant during your initial consultation? And secondly, would you use any kind of breast sizers during the operation?
Dr Dennis Hurwitz: Mentor has a new, more realistic, sizing system. I have also used the Axis Three 3D imager sizer, which is pretty accurate and very helpful. With a little care, through using sizers and 3D imaging, I have only had one implant size exchange in the last three years.
Dr Luiz Toledo: I have a box of implants in the office that the patients can try on, which I think is the best way. We have special bras for these and I tell patients to come in wearing a t-shirt for the fitting. I also have the mirror image programme that I can show patients and some cohesive implants that are cut in half so patients can see what they look like inside.
Mr Alex Karidis: Many patients come in with a predetermined notion about what size they want to be. I also have a box of implants, special sports bras and a tight fitting top, and ask patients to look in the mirror and see what the implants are like.
The first question patients always ask is “what size does this make me?” I would say it is irrelevant what size it is. What is important is that if the patient likes the look, ignore the cup size. If you tell them it’s going to be a D cup or an E cup, they will hold you to that. They’ll then say, “I went to my bra fitter and he said it was a C cup or a D cup.” So forget about size—it’s what it looks like that is important.
Dr Riccardo Frati: At the start, I take some measurements from the patient and ask about expectations. This guides me to suggest a range of three sizes of implant. Then we go to the sizer and try implants with a loose bra and allow the patient to evaluate the look in a mirror. It’s important not to give them all the implant sizes because the patient will get confused, as will you. I also use 3D simulation, but it costs a lot of money and can make false smaller sizes. I prefer patients to try the implants as I don’t believe the 3D simulation systems are accurate.
Mr Shiva Singh: I use the same system. The basic measurement is the base weight and I try to stay within it. I do give them implants and use the bras, but I do then tell them it’s not going to look exactly the same. Bra cup sizes vary from shop to shop so nobody can guarantee the final size—it’s on my consent form that a cup size has not been guaranteed. Invariably, using the base weight and keeping within one centimetre of the width of the breast will give a good result. Then I use my own imagination about projection; whether to go for medium, high or low profile implants.
Dr Luiz Toledo: If a patient is undecided between a 300cc and a 350cc implant, I tell them to go for the 350cc—I’ve never had a patient coming back and asking for a smaller implant, but I do have patients wanting a bigger one.
Dr Dennis Hurwitz: I advise the patient that I am here to tell them what’s best for them and what’s realistic. If a patient has a small, narrow chest and wants an implant, you have to guide them away from one that is too big. If they insist and choose a bigger size than their body can handle, then they have to understand the repercussions of that. If a patient selects a size that I think is too big, I would say so.