Breast Implant Exchange After Reconstruction - When Planning Only Gets You So Far

This case is different from the overseas surgery posts on this blog. Poor documentation, inadequate surgical planning, and suboptimal practice can occur anywhere, regardless of geography. The lesson is the same for patients - really ask questions of your surgeon, and know what documentation you are entitled to.

Background

A patient with bilateral breast cancer had undergone mastectomy and direct implant reconstruction on both sides - one over ten years ago, the other approximately five years ago. She presented with an ultrasound findings suggestive of intra-capsular rupture of the older implant requiring exchange.

The more recent side had documented implant details: 395cc, with a lowered and mesh-reinforced inframammary fold (IMF) (i.e. breast fold). My preference is to avoid introducing additional foreign bodies beyond the implant itself. The need for IMF reconstruction can and should be avoided with proper planning, but this was a documented decision from before.

The older side had nothing. No operative note. No implant card. No record of what had been placed or in what plane. This is an unacceptable gap with direct surgical consequences as follows.

Why Documentation Matters

Operative notes and implant cards are specific to the patient. Without them, the surgeon managing any future revision is working blind. Unfortunately, this happens not infrequently.

The explanted implant turned out to be 640cc, anatomical and placed sub-pectoral (under the chest muscle). Contrast this with the 395cc on the other side. A 245cc difference (almost 60%) in a bilateral reconstruction, with no documented rationale. Whatever the chest wall anatomy, this falls outside any reasonable definition of symmetry. The size and weight of that 640cc implant over a decade almost certainly contributed to what was found intra-operatively.

The Role of Sizers

The plan was implant exchange with capsulotomy (enlarging the pocket) or capsulorrhaphy (reducing it) depending on intraoperative findings. A sizer (like a temporary breast implant to guide correct size selection of the actual implant to use) was ordered specifically for this case. Once the old implant was explanted (its size was unknown in advance), the resulting pocket could have been too large or too small for the intended replacement. A sizer thus allows the pocket to be assessed and corrected first (if necessary), with the final implant opened only once the geometry is confirmed. Reference for implant choice was based on the other side, where dimensions were documented, fortunately.

Opening implants that are ultimately unused is not trivial as each is charged to the patient regardless of whether it is implanted. A sizer is thus essential given such a scenario with so many unknowns.

Intra-operative Findings: When the Plan Changes

Through the mastectomy scar, the pectoralis major (chest muscle) fibres were split and the capsule opened. Intra-capsular rupture was confirmed with gross silicone soilage, which was thoroughly washed out. The implant was explanted and confirmed to be 640cc (see picture below, red arrow on right).

The pocket was now obviously too wide, especially laterally, which measured around 16cm. Notice how the width of the explanted implant is already more than the 15 cm of the ruler in the picture above. The 395cc replacement has a width of 12.5cm; accounting for soft tissue, the lateral pocket edge should sit at approximately 13cm. The discrepancy raises a question the records cannot answer: was this stretching over time from a large, heavy implant or was the original implant oversized from the outset, its footprint placed beyond the natural breast boundaries?

The sizer (375cc) was placed and the lateral pocket closed by almost 3cm (from 16 to 13 cm) before the geometry was acceptable. The sizer was then replaced with the final 395cc implant. No two breasts are completely symmetrical, and this is especially true in reconstruction where chest wall anatomy, soft tissue, and prior surgical history all influence the result. The goal was the best achievable symmetry given the circumstances and that was successfully achieved.

The patient was reviewed at two and four days post-operatively. The wound was soft and intact, the implant positioned correctly, and swelling was in keeping with the early post-operative period. She was symmetrical in clothing, happy with the result, and keen to address the other side next. She returned to her home country on day five.

What Else Was Considered

The patient was keen to address the older side first given the documented rupture and its age, a not unreasonable decision.

ADM (acellular dermal matrix) was discussed but not used due to the risks of seroma, infection and red breast syndrome (9.8% risk which increases with increasing patient age). The lateral pocket correction was achieved with the patient's own tissue, which is my preference. The implant is already a foreign body, so where the surgical goal can be achieved without adding another, that is my preferred approach.

For future planning, SIEF (Simultaneous Implant Exchange with Fat Grafting) is a viable alternative for patients who do not want the long-term implications of implants. Implants are not permanent; they require monitoring, carry rupture risk, and will likely need revision further down the line. SIEF can also achieve comparable volumes of 300-400cc using the patient's own fat, with a lower risk profile and no ongoing maintenance burden. For the right patient, it can be a more sustainable solution.

Takeaway

Pre-operative planning sets the framework. Intra-operative judgment determines the outcome.

The planning here was more challenging than usual, with an unknown implant, unknown pocket, and unreliable contralateral side for reference. The framework was built from ultrasound findings, clinical assessment, and a sizer ordered for the case. When the pocket was wider than anticipated, the plan changed accordingly.

Operative efficiency is a reflection of the surgeon's preparation and experience, not corners cut. A surgeon should be able to anticipate the approximate time a procedure will require, so saying 2-6 hours means nothing in this context. When there is a striking difference in operative time between surgeons doing essentially the same procedure, the question worth asking is: is it fair for the patient or insurer to subsidise what is possibly the surgeon's on-the-job learning?

Looking further ahead, bilateral DIEP flap reconstruction remains an option as that is the gold standard where sufficient donor tissue from the abdomen is available. It is a significant undertaking. But it raises a question worth sitting with: if microsurgical flap reconstruction was feasible from the beginning, why was it not the primary plan over a decade ago?

As this case demonstrates, the consequences of not having an implant card and operative records can surface years later with downstream effects.

References

• Bae J, Sohn JY, Lee J, Cho J, Pyon JK. Early Onset Red Breast Syndrome: The Incidence, Risk Factors, and Clinical Outcomes in Prepectoral Direct-to-Implant Breast Reconstruction. Aesthet Surg J. 2025 Jun 16;45(7):673-682. doi: 10.1093/asj/sjaf035. PMID: 40323049.

• Del Vecchio DA. "SIEF"--simultaneous implant exchange with fat: a new option in revision breast implant surgery. Plast Reconstr Surg. 2012 Dec;130(6):1187-1196. doi: 10.1097/PRS.0b013e31826d9c3c. PMID: 23190803.

• Ohashi M, Yamakawa M, Chiba A, Nagano H, Nakai H. Our Experience with 131 Cases of Simultaneous Breast Implant Exhange with Fat (SIEF). Plast Reconstr Surg Glob Open. 2016 Apr 25;4(4):e691. doi: 10.1097/GOX.0000000000000601. PMID: 27200253; PMCID: PMC4859250.

For patients with concerns about existing breast implants, you can read more about breast implant complications and SIEF at ZNG. For patients considering breast reconstruction, you can read more about implant-based and microsurgical breast reconstruction at ZNG.

Written by Dr Ng Zhi Yang, Singapore Plastic Surgeon, and Founder & Medical Director of Doctor Stitch, a specialist-led cosmetic surgery aftercare service.