After breast augmentation surgery with a silicone implant, the displacement of the implant from its proper position on the rib cage is known as “silicone implant displacement,” and it is referred to as “implant malposition” in the plastic surgery literature.
A study conducted in the United States reported that approximately 5% of patients who underwent breast augmentation surgery experienced silicone implant malposition within 10 years. “Capsular contracture” and “silicone implant malposition” are the most common problems that necessitate a revision surgery in the years after the breast augmentation surgery. In this article, I wanted to clarify one of the problems that can be observed in the breasts due to silicone breast implants.
Where Is The Normal Location Of A Silicone Implant?
To describe it simply: the silicone implant should be right under the breast tissue, with the nipple on it right in the middle of it. If we imagine a vertical line passing through a normal, non-drooping nipple, half of the implant should remain in the inner side and the other half in the outer side of the breast.
The implant will droop gradually, with 60% of it lying below the nipple. The way to achieve this ratio is to properly prepare the pouch, where the silicone implant will be placed, and to use the correct size breast silicone implant that is compatible with the breast base diameter.
If we imagine a horizontal line passing through the nipple, the most protruding portion of the implant should be positioned to be under the nipple. Positioning the implant to be below or above the nipple malpositions the nipple and impairs the overall appearance of the breast. Another critical point is to position the inframammary correctly and make sure that the silicone implant does not extend below it.
What Are The Types of Silicone Breast Implant Malposition (Displacement)?
When the nipple is taken as a reference, we can say that silicone implants can be displaced upward, downward, inward, or outward, in other words, in all directions. Displacement of the implant from the correct position to another not only impairs the overall appearance of the breast, but also changes the direction of the nipple; and as a result, the nipple turns in the opposite direction of the direction in which the implant slides, resulting in an aesthetically very unsightly appearance.
Upward Malposition: In this type of silicone implant malposition, the greater portion of the silicone implant remains above the nipple, with the nipple pointing downward. There is no fullness in the lower half of the breast that should exist. This problem is more common in cases where the silicone implants are placed through an incision made under the armpit. In people who wear supportive bras all the time to make their cleavage area fuller, the implant may slide upwards.. Capsular contracture, which develops in the late period, is another cause of upward malposition.
In the years following the surgery, it may seem as if the implant has shifted upwards as a result of the breast tissue sliding down over the silicone implant, but this a different condition that requires a different treatment. In cases with a real upward malposition, the implant is positioned lower; or the implant is left in place, and the breast tissue that has shifted downwards is raised by performing the breast lift procedure.
Downward Malposition: It is a condition, in which the greater portion of the silicone implant remains below the nipple. The distance between the nipple and the inframammary fold has increased. The breast skin below the nipple is looser stretched. The portion of the breast above the nipple is no longer full. The nipples are pointing upwards instead of forwards.
In the literature, this condition is referred to as “bottoming out” deformity. In some cases of downward malposition, the implant goes below the inframammary fold, creating a second submammary fold. Such deformities caused by downward malposition are called “double bubble” deformities.
In general, downward malposition of the silicone implant can be caused by a variety of factors. The lower border of the pouch created during surgery may be too large. On the other hand, the implant may slip downward over time due its weight and the excessive looseness of the breast tissue and skin. In cases where the implant is placed in a subpectoral (submuscular) plane, the muscle may push the implant downwards over time in athletes who use their chest muscles excessively.
Outward Malposition: In case of outward malposition of the silicone implant, the implant has shifted toward the outside and side of the body, to a location close to the armpit. The breasts look to more separated from each other. The nipples point inward. It is more common in people with excessively loose breast skin and in cases where the rib cage is excessively curved. It can also be caused by an improperly created pouch, where the implant has been placed during the surgery.
It is commonly observed when a surgeon attempts to place implants with a volume greater than the diameter of the breast’s base. Implants move outward and downward due to their own weight. In people who have the habit of constantly lying on their faces, outward malposition of silicone implants can be observed in the early postoperative period.
Inward Malposition: The bigger proportion of the silicone implant remains in the inner side of the breast if we imagine a vertical line passing through the nipple. The nipples relatively point outward. It is caused by prolonged postoperative use of supportive bras which push the implants inward to make the breasts look closer to each other.
What are the Causes of Silicone Implant Malposition?
Causes Related to The Surgical Technique: Malposition can occur if the pouch where the silicone implant will be placed is not prepared properly during the surgery. In cases where the pouch is created wider than the implant, the implant shifts towards the wider side. In cases where the pouch is created narrower than the implant, the implant usually shifts upwards or outwards. In such a case, the risk of capsular contracture increases. If the pouch is created in the submuscular plane, the portion of the pectoral muscle below the nipple should be adequately liberated.
Otherwise, the implant remains above the correct position. Implants placed through incisions made on the armpit or areola pose a higher risk of malposition. Compared to implants placed in the submuscular plane, implants placed in a subglandular (supramuscular) plane are more likely to cause a malposition problem. The incidence of each of these problems is inversely correlated with the plastic surgeon’s level of experience.
Causes of Malposition Due To Silicone Implants: Due to their sizes and weights, large-sized implants are more likely to cause silicone implant malposition. Smooth-surfaced implants are more likely to get displaced than implants with textured surfaces.
Patient-Related Causes of Silicone Implant Malposition: Developmental disorders in the rib cage or breasts of the patient may lead to malposition problems.
- As in cases of tuberous breast deformity, patients with underdeveloped breast skin and inframammary folds positioned at a level higher than normal are at a higher risk of developing a “double bubble deformity”.
- Breast tissue decreases and the breast skin loses its elasticity, loosens, and gets displaced as a result of aging, pregnancy, and excessive weight gain and loss.
- If the rib cage has a “pigeon chest (pectus carinatum)” deformity, the implant tends to shift outward. The “pectus excavatum” deformity increases the risk of inward displacement of the implant.
- Because of its own weight, the implant shifts downward more easily if adequate capsule tissue does not develop around the silicone implant in the postoperative period. On the other hand, in case of capsular contracture that is a late postoperative complication, the breast gets deformed and the implant gets harder and displaced.
- Wearing bras that push the implants upwards and inwards to highlight the cleavage area is another common cause of implant malposition.
- If the breast tissue is also loose in people who have the habit of constantly lying on their faces, outward or downward implant malposition may be observed over time.
Treatment of Silicone Malposition
First, a detailed examination reveals the causes of silicone implant malposition. The evaluation involves the rib cage structure, looseness of the breast tissue, condition of the capsule around the implant, dimensions of the implant, and condition of the prepared pouch. Typically, more than one cause is identified, and a systematic approach to the elimination of each cause in the treatment is determined.
Changing the Size or Shape of the Silicone implant: If the volume and diameter of the implant is much larger compared to the base of the breast, there may be a corresponding downward and outward displacement. In such a case, the large implant is removed and replaced with an implant of the correct base diameter and volume.
Revision of the pouch where the implant has been placed: The pouch, towards which the silicone implant has shifted, that is, the implant has gotten malpositioned, is narrowed using different techniques. The pouch just opposite the narrowed pouch is enlarged.
Creating a New Pouch: The pouch created in the breast for the silicone implant can be canceled to create a new one. An implant placed in a supramuscular (subglandular-submammary) plane can be placed in a newly prepared submuscular (dual subpectoral) plane. In cases where the silicone implant has been placed submuscularly in the breast, a new pouch can be prepared in a supramuscular plan or under the muscle with the anterior wall of the existing capsule.
Correct Positioning Of The Inframammary Fold: The inframammary fold could be positioned above or below the normal level. This fold is recreated and strengthened in the right position.
Liberation of The Chest Muscle: The dual plan, also known as the partial subpectoral plan, is one of the most common pouch preparation approaches. In this technique, the pectoral muscle is liberated by making an incision downward from the level of the nipple to the point where this muscle attaches to the sternum. If this liberation process has not been carried of adequately, the implant will shift upwards and outward whenever the muscle contracts. In such cases, the chest muscle is liberated more, allowing the implant to move up and down.
What Can Be Done to Prevent Silicone implant Malposition?
There are several points that the plastic surgeon and the patient should be careful about to avoid silicone implant malposition in the breast. The structures and dimensions of the rib cage and breast should be thoroughly evaluated during the preoperative examination and preliminary interview.
- A silicone implant in a size and volume suitable for the diameter of the breast base should be chosen. It should not be attempted to place a large implant that would push the limits.
- The pouch where the silicone implant will be placed should be properly created in the breast and should be compatible with the implant size. Pouches should not be too big or too small.
- During the postoperative period, the patient should wear a special bra corset. This bra should be compatible with the breast dimensions and should support the breast three-dimensionally to hold it in place.
- Special supportive bras that push the silicone implant towards the cleavage area should not be worn constantly.
- The patient should not lie face down for a period of at least 3 months after the operation.
- In cases where the silicone implant has been placed in a submuscular plan, patients should avoid physically demanding sports such as tennis, swimming, pull-ups, push-ups, or weight lifting for at least 2 months. Athlete bras should be worn while doing such sports activities in the following periods.
- Routine massage on the implants should be avoided in the postoperative period. If the surgeon recommends massage, it should be done as instructed and as frequently as he/she suggests.