I want to get rid of my breast implants- what now?

Many patients come to the office considering removing their breast implants that they had placed years ago.  Often times, they have had their breast implants for a few decades and say that they enjoyed them, but just do not want them anymore.  In some cases, it is because the patient would like less bulk to carry while she is exercising. 

In other cases, she might feel that her breast fullness no longer suits her current age and social situation.  Furthermore, some patients simply feel like they are just entering a different phase of their life, and breast fullness is no longer important to them.

Even though patients often know that they want to have their current breast implants removed, they are stuck in the decision process of what to do because they do not know what the options are after breast implant removal.  The patients are rightly concerned that, after they remove their implants, their breasts will be deflated and saggy. 

In my experience, that is very often the case, but certainly there are some situations in which the patient could be surprised by how good they still look after removing the implants.  Nonetheless, it is best to enter into this process with knowledge of all the options available.

I like to discuss this thought process as involving a range of options, one of which is as simple as leaving the implants in place. Sometimes, patients feel like they must do something with their breast implants because they have been in a long time, but they are actually reasonably happy with the appearance. 

I can counsel these patients that, if they are not having any issues with the implants, there is no medical indication to remove them or replace them after any given period of time.  Sometimes patients will be relieved by the fact that nothing actually needs to be done and go on their way happily with their implants still in place.

In reality, most patients come knowing that they want something done to change their breast.  The simplest thing that I present them is just removing their breast implants.  The patients wisely question whether that will leave them with a horrible cosmetic result. 

The answer to this really depends on how much breast tissue the patient has.  Some patients are fortunate enough to have reasonably firm, elastic skin, and enough breast tissue and fat that removing the implants can leave a very reasonable appearance.  In fact, 15 or 20 years ago, the common thought was that patients would always look terrible after the implants were removed.  I have been pleasantly surprised, as have many of my patients, by the very acceptable appearance and reasonable A-cup/small B-cup size breast that many patients still have after removing breast implants.  Unfortunately, this is not the case when patients have very thin tissues or the breasts are very droopy.

Usually, when I see patients for removal of implants that they have had for many, many years, they have developed some droopiness over that time.  This can refer to either stretched out skin, or nipples that are very low, towards the bottom of the breast, even pointing at the floor.  With drooping of this sort, simply removing the implants does very little to improve the cosmetic appearance of the breast. 

If the patient definitely wants to have the implant removed and wants to avoid the droopiness and tighten up the skin envelope to make the breast perky (albeit smaller), a breast lift is usually performed.  I can simulate the concept of tightening up the extra skin by gathering the extra skin and pinching in my fingers so that the rest of the breast tissue gets pushed up higher into a perky position, but when there is an implant already in place, it can be hard to conceptualize what the final result will be. 

It is for this reason that deciding to remove an implant and do a lift can be a challenging decision.  The tradeoff for any lift is the presence of scars afterwards (almost always in an anchor type pattern).  Nonetheless, if someone is not worried about their size or actually prefers to have small breasts, is not concerned about maintaining fullness to the upper part of their breast, and is not concerned about scars, then simply removing the implants and doing a breast lift can be the best option.  This is a very common choice.

Other patients are not so worried about droopiness and prefer not to have the scars, but are just tired about carrying around heavy implants.  The more we talk about things, the patients sometimes realize that they will be happy with just smaller implants. 

Without question, putting in smaller implants will always make the tissues looser than they were with the larger implants stretching the tissue out and making things firm, but for many patients, this is not a particular concern.  For these patients, simply removing a larger implant and putting in a smaller implant is particularly simple option.  Even better, the patient can always do a lift later if she decides that she would like to have the skin tightened or to have the nipple positioned higher.

Finally, the most complex, but often popular choice is the idea of removing the current implant, putting in a much smaller implant and doing a lift.  One reason to do this is because the patient is worried that they would not have any meaningful volume at all when the current implant is removed. 

The other reason is so that that they can have some fullness at the top of their breast and some cleavage, instead of having this area completely empty or even concave once the implant is removed.  Of course, this choice requires the same scars as breast lift, but the scars can seem less noticeable when the breast is not so small.

Finally, patients often ask about fat grafting once the implants are removed.  Fat grafting is an excellent procedure to add conservative amounts of volume to her breast.  In general, the maximum volume that can be added to the breast with a single fat grafting procedure equates to approximately one cup size.  This is not the case after removal of breast implants.  If you think about it, when the breast implants are removed, there is usually very little tissue left (which is why these decisions are so challenging for patients). 

When there is very little tissue left, there is really not enough tissue to inject fat into.  Even if there is plenty of fat to be harvested from the abdomen/hips/etc., it does not help if there is not enough breast tissue to “plant” this fat into.  I always suggest that it is like having a small garden, and wanting to grow a whole lot of plants in it.  It is not that there are not enough seeds, it is just that there is not enough space to plant all these seeds. 

For this reason, fat grafting is often not a good option in this particular situation.  On occasion, a conservative amount of fat can be placed into the upper pole of the breast, but this is not the majority of cases.

Before completing this discussion, there is a very interesting option for some patients who want to “test drive” their options before they commit.  If a patient has saline implants, and she is 100% sure she wants to have surgery to remove the current implants, but is not sure if she wants lift, no implants, smaller implants, or even a lift with implants, there is a way that she can preview this. 

A week before the patient’s surgery, we can have them come into the office and we can numb the skin and use a small needle to remove the saline from the current saline implants.  In this way, they can look in the mirror and see exactly what they look like if all we do is remove the implants. 

They can either say that would be fine, or say that they want some small implant placed back in, or that they want a lift (once I show them what it would look like by bunching the skin together under the breast) or they want an implant with a lift.  This is a tremendous tool to use in planning the surgery to make sure that the patient is happy with the result.  Unfortunately, this cannot be done with silicone implants, which is the majority of patients these days.

In conclusion, the choice to remove implants is easier than the choice of what to do after the implants are removed.  Hopefully, I have shed some light on this subject and readers can consider the options in their future.

Frederick G. Weniger, MD, MBA, FACS