One of the frustrating problems that can sometimes occur after breast implant surgery is known as “rippling” – an irregular wavy look or feel to the breast. This is caused by a combination of factors, related to the physical properties of the implant, the patient’s own soft tissue and how it may have changed over time, and the choice of implant pocket design (“over vs. under”).
Plastic surgeons generally divide these problems into 2 main categories, based on why they’ve happened.
1. Shell rippling
2. Traction rippling
Shell rippling is the most common problem of this kind I see, and is the topic for today. (I’ll discuss traction ripples in a later blog.) The classic scenario is with a subglandular (“over”) saline-filled implant in a slender woman who doesn’t have very much tissue coverage over the implant. Typically, the breasts looked OK for a period of time, and then, ripples started to show up later.
The usual way to improve this situation is to operate, and get more tissue coverage over the implant, by converting it to a sub-pectoral position. This move significantly improves ripples in the upper portion of the breast – which is the area most exposed by low neckline fashions. The other solution is to change the saline implant to a silicone gel implant, which has been shown in studies to have a ripple rate of approximately 1%, as opposed to the ripple rate of saline implants, at about 10%. I usually prefer to use both methods – getting muscle coverage over a gel implant. It works well to fix this problem.
Shell ripples occur for several reasons: they have to do with the tendency of the elastomeric implant shell to want to fold in on itself, the amount of fill in the implant, the viscosity of the fill material in the implant, and the pressure applied by the surrounding soft tissue. They are disguised by the amount of soft tissue thickness over the implant. Often, with the passage of time, there is thinning out of the breast tissue adjacent to the implant, and implants that were adequately covered early post-op may become more obviously rippled over time.
Saline implants, having the lowest viscosity filler, will ripple the most. Currently available silicone gel implants, having a moderate viscosity filler, ripple a lot less. The “form stable” gummy bear implants, with their high viscosity silicone filler, should ripple even less than the current generation of gel implants. Early data from Europe seems to support this concept.
Women interested in saline implants often ask about the concept of “over-filling”, which is just adding more saline solution in the implant bag, beyond the manufacturer’s recommended range. There are pro’s and con’s to this approach. Certainly, more fluid will reduce some of the emptiness and collapse of the implant shell seen when the saline implant is in the vertical position. It also makes the implant larger, rounder, less natural looking, and a little more firm. It also potentially voids the manufacturer’s warranty. If you over-do the over-filling, you start to see a new type of wrinkling – tension bands around the equator of the implant. So overfilling is only partially helpful- and as we’ve discussed, it only addresses one of the multiple factors that are involved with ripple formation.
The soft tissue pocket is also important. If there is a significant amount of capsular contracture, the soft tissue envelope may actually distort the shape of the implant, and cause it to fold on itself. This can cause a knuckle-like point to occur in the implant, which patients may be able to feel through the skin. Implant folds can lead to early implant failure. So, when you are fixing ripple issues, any capsule issues will need to be addressed surgically as well.
Take home message: ripples are related to the combination of thin soft tissue coverage, combined with the engineering limitations of the current generation of breast implant devices. If you are slender up top, and can feel or see your ribs on the side of your rib cage, you should give some thought to sub-pectoral implant placement of a gel implant, if you want to do everything currently possible to minimize your risk of ripple issues post-op.
For some ultra-skinny women, even sub-pectoral gel implants will have some ripples. While weight gain would help, very few women want to hear that they should gain a few pounds! Here, our treatment options are limited – placement of a layer of alloderm or strattice (very expensive), fat grafting to the breast (technically difficult), or perhaps injections of commercially available fillers. It remains to be seen whether the new generation of form-stable breast implants will be a good answer or not for this group of patients.