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Downsizing the Breast Augmentation Patient
Finny George1, Mark Sultan, M.D.2.
1Montefiore Medical Center, Bronx, NY, USA, 2Roosevelt Hospital, New York, NY, USA.

Breast augmentation is generally a highly gratifying procedure for both patient and surgeon. It often enhances a women's sense of well-being by improving her breast size and shape. There are instances, however, when patients feel that their implants are too large and they request replacement with significantly smaller implants. "Downsizing" can be challenging procedures because of the difficulties posed by excessive or lax soft tissue envelopes in addition to the presence of capsules, which can be considerably larger than the new smaller implants. There is little information on this subject in our literature. We, therefore, present our experience with downsizing of breast implants.
We retrospectively reviewed the charts of consecutive breast augmentation patients who requested replacement of their breast implants with smaller sized implants from 2009 to 2013. Given the inherent mismatch in envelope size relative to the new implant, the surgeon is faced with a challenging problem. Options include capsulorrhaphies, with or without dermal graft reinforcement, mastopexies or a combination of both to allow for proper reduction in pocket size while preserving or improving the aesthetic contour of the breast mound. Patient demographics, implant characteristics, operative details and long-term outcomes - including complications and revisions - were analyzed.
Seven patients, between 28 and 45 years of age, underwent a significant downsizing procedure in this time period (defined as greater than 20% of the original implant volume). Of these patients, four had silicone implants and three had saline. All of the patients requested replacement with silicone implants. We found that 86% of patients required mastopexy procedures, 28% required acellular dermal matrix and 100% required capsulorrhaphies. Six out of seven patients required both capsulorrhaphy and mastopexy.
Minor complications occurred in three patients including small self-limited seromata in two and mild rippling in one. All patients were highly pleased with their new smaller breast volume and their aesthetic results. At a follow-up of at least 1 year, none have requested or required revisions.
"Downsizing" is a topic that is infrequently discussed in our literature, but is encountered in practice. By analyzing patient needs and addressing the tissue envelope precisely, we can deliver a consistent and excellent outcome for our patients.

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