Dear Roy:

I have just received this picture from a patient operated on in April 2004. She has Kenalog in the saline in her implants.

Did you say at the meeting, that you had experienced, that when you had emptied the implants, and refilled with pure saline, the skin had retracted and the

thinning had disappeared? Would you suggest me to take out the implants for a couple of months?



Hi and I am happy to hear from you.

Yes that is what I said. Wash out the implants and the pockets thoroughly and the blue window will quickly fade away and return to normal looking skin in my experience over many years with more than a dozen blue windows due to steriods.

I just saw a patient and old friend, a nurse who used to work with us, last week. She was one of my many blue windows 15 years ago and now she is fine and with no problems.

Yes, immediately when the implants are removed , washed out and replaced, and I don't know if they can be removed intact or not through the axilla. Dan does it because he inserts them filled and so he can always get them out through the axilla, but they might break if I were doing it.

Never the less, however you get them out, you will see immediate improvement in the thin blue areas. The next day they will look much better.

I would wash them out if they are intact and get every tiny bit of kenalog out and then fill them again if they are intact and not leaking and re insert them, after irrigating the pockets with saline.

Either through the areola or through the axilla, at surgery, with the low implant position and the thin skin below, I would choose to put the implants in a subfascial or subglandular position. That will allow them to come up some and not have the muscle pressure pushing them down.

I have seen submuscular pressure against the soft blue window of steroids stretch out a blue area and lower implants much more than this picture shows that this patient has now.

Since the implants are a little low at this time it might be desirable to lift them some. It all depends on her wishes and whether or not she likes or dislikes the present position.

Many patients have different opinions and one of my patients in the last few months had one implant that I thought was a little bit lower then the other and I offered to lift it. She thought about it for a few weeks and talked with her girlfriends about it and their consensus of wisdom was that the one I liked the best and felt was most normal and most centered behind the nipple  should be lowered because they all agreed that the lower one with the nipple pointing a little more up was the more desirable shape. The difference was small and so in her case instead of surgery we are having her put a little pressure on the higher side to push it down more and she is happy.

Many persons and patients like the implants like that ( a little low) with the nipples pointed up and on David Hendrick's wonderful dvd of surgery, which I hope you got and if you didn't I'll send it to you, he mentions such an opinion, both from his office staff and from the patient.

If though, all agree that the implants are too low, I would consider the following steps that can be done when the implants are washed out to remove all the kenalog and replace it with saline.

They are:

1. Suturing  the deep dermis to the deeper structures of the chest wall all the way down to the periosteum with permanent monofilament interrupted sutures such as a 4-0 clear nylon or prolene,  to create a new, strong and  higher inframammary fold. I would consider also putting a second layer of absorbable suture above this to allow the permanent repair to heal without pressure of the gravity of the implants - over correcting the lifting of the inframammary fold by 0.5 to one centimeter, knowing that the temporary layer will weaken and absorb away in a few weeks. For this I would probably choose 4-0 pds.

2. Since she is probably under the muscle, this supporting suturing might not do any good because the muscles are pressing the implants down. Therefore, I would place her implants in a subfascial position rather than leaving her submuscular.

3. The fascia or capsule under the implants is probably quite as thin as the skin is and yet in my experience it can usually be lifted high at about the level of the nipple with a transverse incision. It can be dissected down as a thin or possibly in some cases a reasonably  thick later of more than a millimeter from that level to add a layer of thickness to the skin and hasten recovery.

4. If desired, a deeper dissection of fascia of the serratus and rectus abdominus can be lifted up and folded out from the chest to form a curved shelf for the new inframammary fold. It will seem to be fairly strong at the time, but in my experience even this shelf of strong fascia will not necessarily hold up the implants that are in a submuscular position because of the downward pressure from the pectoral muscle over the implant when the muscle is contracted. To get a feel of how much pressure this is, the examiner can stand behind the patient with each hand cupped under the breast holding the implants up as the patient is asked to press the palms together and contract both pectoral muscles. The downward pressure with this maneuver can be felt to be quite considerable. 

5. After surgery I would probably hold them up with the skin adhesive Mastisol, which is a clear sort of tincture of benzoin, followed by white paper tape, because the 3M white paper sticks better than the brown. Then for her appearance I would cover the white paper tape with brown 3M paper tape, and tape all the way around the chest for a week or two, being careful not to compress the thin area so much as to impair the blood supply. I would describe this taping to her before the surgery so she expects it.

6. Then I would consider some type of elastic or Velcro bandage either over the shoulder and under the breast holding each one up separately or just around the chest over the tape - or both. Her comfort is most important or she will no like it and leave it off too much. Ladies, however, are accustomed to being told to sleep in a bra, and they will usually do that over the tape without much complaint. With the bra off and the tape still on she can still briefly shower and shampoo trying not to soak the tape too much.

In conclusion, whenever the kenalog is removed from the implants, the pocket is also thoroughly irrigated with saline and the implants are replaced, the improvement in the blue window appearance is dramatic and can be seen within 24 hours.

I have had the problem of blue windows and treated it in about 20 patients because of my experience using steroids on every patient from about 1975 through 1988 when I was using double lumen implants with saline over gel. All the blue windows completely disappeared and there were no extrusions or infections or loss of the implants.

The upward repositioning of the implants can be done if needed and is successful almost always if they are not submuscular.

Thank you. Happy to hear from you and hope you let me know what happens.

Yours truly,


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