implants need to be removed, but what then?
Tell me your proposal,
Reply Hi :
From 1976 thru 1986 I used double
lumen implants with the silicone gel covered by saline in an outer
shell with a ratio of about four to one - gel to saline volume, so
that an implant might have 300cc gel and 60cc saline.
This was to keep the implants soft
and routinely I put a little cortisone in the outer lumen with the
It worked and they stayed soft and
I hardly ever had a firm breast in the first 3 years after surgery.
I used some Solumedrol at about
20mg, but it seemed to me we wanted it to last longer, so I also used
I had a lot of blue windows and
found that the dose of 20 mg of kenalog per implant would cause a blue
window half the time. So I would use between 2mg and up to 10mg
kenalog depending on the patient’s tendency to scar, to keloid, and
the thinness or thickness of the tissue inferiorly below the nipple.
If I saw the patient early with a
blue window, in the first year, I might take out the implant and wash
it out and replace it with plain saline and a blue window as you see
it there in your picture, would be gone within a month.
Every time. Without fail simply
washing out the steroid and replacing the implant allowed the tissues
in the thin blue window area to thicken and become normal very quickly
over a period of just a month with more thickening in time. In only a
month the blue window was no longer blue and we knew that it was
recovering. Never did I have to remove the implant entirely to get it
to recover and none ever had extrusion.
So therefore, I would like to know
when the kenalog was injected. Probably some oozed or leaked out into
the pocket and didn’t stay in the scar where he wanted to put it.
The time is important because the
tissues thin out over 6 months and then stop and the thinning of
normal tissue dissipates as the tissues thicken back to normal over
another six months to a year or two.
Therefore all the thinning and blue
window will go away in time. And if it is due to steroid it will
eventually correct itself unless there is pressure stretching the thin
She needs support and must not
scratch or have an injury to the thin skin, because if she does, it
can easily break the skin and then you are faced with bacteria that
can cause infection and we might then have to probably remove the
implant for 2-3 months and let it heal and the put one back in without
the bacteria in the pocket.
So if she had the kenalog 6mo or
more ago, I would wait and see her every 2 weeks with photographs just
like you sent me and see if it is improving or not. If it is getting
better as it does after 6mo, the thickening and returning to normal
will be hard to detect in less than a month. It returns to normal
slowly. Sort of watching a tree grow.
As soon as you see it improving and
not getting worse, then I would say yippee and not operate.
If she doesn’t wear support all day
that breast could begin to droop. It is not necessary at night.
If the thinning gets worse or if
the injection was less than 6 mo ago or for a variety of reasons such
has her preference, surgery can be done and hasten recovery.
Some surgeons have been unaware of
the ability of that blue skin to return to normal, and thinking
it permanent have removed skin. And this should not be done,
I have seen blue windows that bad
and worse caused by my kenalog in the implant and seen the skin
return to normal (every time in all cases with more than twenty cases
I have had) in 2-4 weeks after I removed the kenalog from the implant.
So I know in my heart and soul from my own experience with steroid
caused blue windows, that this skin will return to normal. It will do
it quickly over a period of a few weeks, if the steroid is removed.
The surgery I would do to correct
or hasten thickening of this blue window, if it is getting worse and
not better, is to take the pectoral fascia down from off of the
muscle above as a large flap including the fascia under the lower part
of the breast which is from the serratus and rectus and lift it up as
a sheet and fold it down to cover all the blue window area to
strengthen it. The ledge of firm fascia where it is left attached to
the chest wall can become the new inframammary fold and can be higher
than she has now and can repair the drooping that occurs if she is
I have always done this through an
intra-areolar incision because it seems easier that way than
I would like for you to send
several pictures of her, in as many positions as you can, because
this can happen with the inframammary incision and is heartbreaking to
the patient. I have seen many keloids like that from the incision in
that location and have never seen one yet under the arm or with the
intra-areolar incision, which heals differently and better because it
is essentially mucosa covered by epidermis.
So please email me more pictures of
her if you can .And let me know what happens.
William Roy Morgan, M.D., F.A.C.S.
1419 Superior Avenue #2
ascbs web site is ascbs.org
web site is
Thank you for your excellent
essay concerning the treatment of “blue windows” I saw the young
lady yesterday and the blue window didn't either look better or worse. Look at the right picture for comparison.
The skin looks the same even though the picture came out with more of
a blue color. It
looks more blue on the picture than in reality.
She was quite happy when I
explained to her that the blue window may vanish in time. The cortisone
medication was applied some months ago. I gave her information on how
to be protective and careful of the thin skin, to have the breast supported by a bra and to avoid any
rubbing or scratches on that fragile skin. In case of any moisture
that might be excreted she should return immediately r to show me. In
case there is no change or any improvement she should return to let me
see her just about every month or more often until we see improvement
and thickening of the skin.
If there is any sign of
worsening or no improvement in follow up, we will do the surgery
dissecting the fascia as a layer of tissue to place down over the thin
skin. It is expected that the fascia is probably thinned just like the
skin is and yet it should be thick enough to help and get a good
repair. If not, we will just need to perhaps remove the implant for a
few months and then plan to replace it after the skin has returned to
normal. Neither the patient or I want to do that, so we hope it will
gradually improve and recover completely as you have seen.
Looking forward to seeing you