Reoperative Aesthetic & Reconstructive Plastic Surgery

1276
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
This patient demonstrates the effect of implant descent. Two years earlier steroids
had been inserted into the implant pocket. The reoperative result is shown 1 year
after correction using the technique described previously.
Implant-site change is an alternative way to correct inferior descent. Site change
should be strongly considered for patients who have undergone reoperations that
have failed to correct malposition. If the primary pocket was subglandular, the im-
plant is reinserted in the subpectoral position. The subglandular pocket should be
closed with a few sutures or partial capsulectomy. Relocation of the implant pre-
vents recurrence of malposition, which can occur if the inferior ap dehisces from
the fascial plication.

1277
Chapter 34
Reoperative Surgery Following Breast Augmentation
This 45-year-old patient had previously undergone augmentation with subglan-
dular, double-lumen silicone gel implants. She was referred for correction 1 year
later after two additional procedures to correct implant malposition had been per-
formed.The surgeon had attempted replacement of the implants with plication of
the inframammary fold, but persistent herniation ensued with irregularities along
the inframammary fold. Correction was accomplished by carefully suturing inferior
and lateral to the reopened capsule along the projected level of the inframammary
fold. A textured-surface implant was placed in the subpectoral position.
The patient is shown 1 year postoperatively.The correction has been maintained.

1278
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
When a large implant is placed in a small breast without adequately lowering the
inframammary fold, a high-riding implant may result. This problem can often be
treated using a superiorly placed compression strap. If this approach fails, surgical
lowering of the implant is required. When implants are placed too far laterally or
when an implant “drifts” postoperatively, the implants should be repositioned and
the lateral pocket reinforced with several rows of sutures. We prefer to open the
capsule anteriorly and posteriorly along the anticipated new lateral border to locate
a part of the wound where solid brosis and healing can be expected to occur. If
this location is not satisfactory, a new site is chosen.
For all malposition problems in which a volume change is also being made so that
new implants are part of the operative plan, we prefer to replace the primary im-
plant with a textured-surface implant. These implants tend to remain where they
are placed if they become adherent to the surrounding capsule. This attachment
will diminish the gravitational forces that tend to allow inferior and lateral implant
movement, especially if the implant is in contact with a fresh noncapsular tissue
interface.
CAPSULAR CONTRACTURE
The development of capsular contracture in the augmented breast is one of the
most frustrating and dif cult problems plastic surgeons face. Numerous causes have
been proposed. Multiple strategies to prevent or reduce its incidence have been
advocated. Despite intensive efforts, capsular contracture remains a common com-
plication of breast augmentation surgery.23
The IOM report24,67 stated that for studies involving both silicone gel– lled and
saline- lled breast implants, the capsular contracture rates were 36% to 81% for sil-
icone gel– lled breast implants and 8% to 41% for saline- lled breast implants.
Manufacturers’ prospective studies of saline- lled breast implants showed rates of
grade III or IV capsular contracture of 9% at 3 years and 10% to 11% at 5 years for
patients who underwent augmentation.
CAUSES
All foreign bodies implanted into the body incite an in ammatory response that re-
sults in the development of a brous capsule. This capsule consists largely of -
broblasts and an associated brous connective tissue matrix.25 In some patients with
breast implants this capsule contracts to varying degrees. A specialized broblast
with smooth muscle characteristics, the myo broblast, has been found in the cap-
sules of patients with contractures and is considered by many to be responsible for
contraction.26 It is not understood what causes myo broblasts to appear in the cap-
sule and what regulates its contraction properties.

A single primary cause of capsular contracture has not been identi ed. Numerous
associations have been proposed in the literature. Although none is conclusive, these
hypotheses at least warrant consideration.
Hematoma has long been associated with increased rates of contracture. Hipps et
al27 reported an 86% incidence of contracture in patients with hematoma versus
32% in patients without hematoma. Animal studies showed histologic evidence of
a thicker capsule around the implants in baboons in which hematomas were al-
lowed to develop.28 The problem with this study is that there is no correlation be-
tween the thickness of a capsule and the likelihood of signi cant contracture devel-
oping. Implants placed in rabbits in which a hematoma was allowed to develop on
one side and not the other failed to show an increased incidence of contracture.29
Finally, the low incidence of hematoma occurrence in patients with breast implants
(the highest is 6%) falls far below the observed incidence of contracture.
Infection has been linked to increased rates of contracture. Several authors have
shown a causal relationship between bacterial contamination and capsular contrac-
ture in animals.24,30 A number of experiments have been reported demonstrating a
relationship between subclinical infection and contracture.31,32 Burkhardt et al33
published a prospective, randomized, double-blind clinical study demonstrating a
signi cant decrease in the incidence of contracture in patients who received local
antibacterial agents at the time of implant placement. Again, the incidence of cap-
sular contracture was far higher than the incidence of infection, de ning infection
as a contributing factor at best.
The discovery of silicone particles in breast implant capsules led some researchers
to believe gel bleed was responsible for contracture.34 This theory was indirectly
supported clinically by a prospective randomized study in which the contracture
rate of saline versus that of gel- lled implants was lower.35 Further evidence was
provided by an animal study in which low-bleed implants had a lower rate of con-
tracture than standard gel- lled implants in rabbits.36 Despite these ndings, con-
tracture has continued to be observed in women with low-bleed implants.
Capsular contracture can be a considerable source of discomfort and dissatisfaction
among patients. Any possible preventive measure should be used. The following
considerations are theoretical and based on percentages.37-41
Although not universally accepted,42 many reports in the literature attribute a lower
incidence of capsular contracture to the placement of implants in the submuscular
versus the subglandular position.43,44 There are a variety of possible explanations.
One is that the muscle repeatedly contracts over the implants, resulting in contin-
uous stretching of the scar. Another possible explanation could relate to the differ-
ent tissue characteristics of the submuscular space, which perhaps make this tissue
less prone to scar contracture than glandular tissue. It is also possible that the sub-
1279
Chapter 34
Reoperative Surgery Following Breast Augmentation

1280
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
muscular space is less vulnerable to contamination by bacteria.45 Further, because
the diagnosis of capsular contracture is largely subjective, the detection of the cap-
sule may be more dif cult in the subpectoral position. Preoperatively, consideration
must be given to natural characteristics such as breast size, degree of ptosis, and
postpartum glandular involution when choosing the most appropriate implant site.
Reducing the incidence of infection has been shown to decrease the rate of con-
tracture for 3 months postoperatively. Burkhardt et al14 demonstrated a statistically
signi cant reduction in capsular contracture rate when any of four antibacterial reg-
imens was implemented. These protocols included intraluminal antibiotic agents
alone and in combination with an irrigation solution, irrigation solution alone,
and povidone-iodine-antibiotic-steroid foam instillation.The antibiotic agent used
was 1 gm cephalothin in 100 cc of normal saline solution.The solution, 30 cc of 5%
povidone-iodine solution, was distributed throughout the pocket. The antibiotic-
steroid foam consisted of a mixture of 50,000 U bacitracin, 250 mg of oxacillin, and
40 mg of triamcinolone.
A number of physicians advocate displacement exercises to decrease the incidence
of contracture.46,47 Patients are instructed to gently massage their breasts during
dressing changes for the rst postoperative week. Then more vigorous daily mas-
sage and even manual releases of brous tissue are performed on a weekly basis. It
is thought that this manipulation preserves the implant pocket volume, thus de-
creasing contracture forces. None of the displacement exercise studies demonstrat-
ing favorable results was controlled for motion exercises alone. In fact, Marshall48 re-
ported better rates of contracture with motion restriction. Textured-surface
implants that adhere to the surrounding capsule will not displace and are not in-
tended to be moved.
The practice of steroid placement in the implant pocket to decrease the incidence
of contracture is based on steroids’inhibitory effects on wound contraction.49 Sev-
eral early reports of success with steroids placed in the implant pocket and within
the lumen of the implant were published.50,51 Long-term follow-up, however, has
demonstrated a signi cant incidence of associated complications including pros-
thesis ptosis, atrophy and thinning of overlying breast tissue, impending extrusion,
and even capsular contracture.52,53

1281
Chapter 34
Reoperative Surgery Following Breast Augmentation
TREATMENT OF CAPSULAR CONTRACTURE
The lowest incidence of capsular contracture is seen among patients who have un-
dergone subpectoral saline augmentation. Capsular contracture has become a rarer
phenomenon in the past decade because of the increased use of saline implants in
the United States and the widespread use of textured cohesive gel implants in the
rest of the world. Nevertheless, capsular contracture continues to be seen and can
be anticipated in patients who have had hematoma or infectious complications.
Prevention may be improved by performing saline implant displacement exercises;
we advise our patients to perform these for a 1-year period postoperatively.
The practice of performing closed capsulotomy54-56 has largely disappeared world-
wide because of manufacturers’recommendations and because it is an uncontrolled
technique in that, when capsular or implant trauma occurs, the exact type of trauma
is unknown.
The surgical treatment of capsular contracture now requires a direct
open approach.
We do not advise early intervention because capsules will often soften sponta-
neously over a 6-month period.When they do not or if they are associated with pa-
tient discomfort, an open capsulotomy is performed. Many of these patients can be
treated in the of ce under local anesthesia, with or without oral sedation.The tech-
nique is demonstrated in the following example.
Open Capsulotomy for Capsular Contracture
Patient Example
This 26-year-old patient presented for saline implant augmentation. A subpectoral
augmentation through an inframammary approach was performed.

1282
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The secondary revision offered to the patient is shown here.The right implant will
be lowered to the level of the inframammary fold on the left side. Radial scoring in-
cisions of the capsule are indicated to allow the implant to descend.
Six months postoperatively, a capsular contracture around the right implant oc-
curred despite implant displacement exercises and a bandeau.

The patient is positioned in a sitting position on the operating table to demon-
strate the amount of release.
1283
Chapter 34
Reoperative Surgery Following Breast Augmentation
This procedure can be performed in the of ce with the patient under local anes-
thesia. The pocket is lled with 50 cc of 0.5% lidocaine with 1:200,000 epineph-
rine.The implant is removed and the scoring incisions and capsular release are ac-
complished using electrocautery.The implant is then replaced.

1284
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Total Capsulectomy for Capsular Contracture
Patient Example
Twenty years earlier, this 40-year-old patient had undergone subglandular breast
augmentation with smooth-surface silicone gel implants. Capsular contracture de-
veloped relatively soon after the primary augmentation, and closed capsulotomy
had resulted in only temporary improvement. Because of continued discomfort
around the implants, she sought correction.
Intraoperatively the capsule was noted to be thick and heavily calci ed. Free cal-
cium deposits were present on and within the capsular wall. A total capsulectomy
was performed along with implant removal. Conversion to saline implants in the
subpectoral position was performed. The patient is shown 3 months postopera-
tively.

DEVICE FAILURE
SALINE-FILLED BREAST IMPLANTS
Saline- lled breast implants rupture/de ate when the saline solution leaks through
either an unsealed or damaged valve, or a break in the implant shell. Implant de a-
tion usually happens immediately but sometimes it happens slowly over a period of
days. De ation of saline- lled breast implants is noticed as a loss of size or shape of
the implant.
Rupture and de ation can occur early or late postoperatively. The IOM report67
stated that the de ation rate reported in the medical literature across studies was 7%
at 7 years. Over time, material fatigue occurs and de ation can result.This material
fatigue usually develops at the site of a fold and has been termed “fold aw leak.”57,58
The IOM report also stated that earlier saline- lled breast implant models had more
deflations than modern models. The IOM estimated that 1% to 3% of modern
saline- lled breast implants would have ruptured by the rst year and that this rate
would increase over time.The modern models show a 5% to 10% rupture rate af-
ter 10 years, according to one study. Prospective studies of saline- lled breast im-
plants approved by the FDA in May 2000 showed rupture/de ation rates of 3% to
5% at 3 years, and 7% to 10% at 5 years for patients who have undergone augmen-
tation.
Patient Example
1285
Chapter 34
Reoperative Surgery Following Breast Augmentation
This patient is shown 4 months after undergoing subpectoral augmentation using
smooth-walled in atable saline breast implants.

1286
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
She returned 2 years after augmentation, having noted a gradually diminishing size
of the left augmented breast over a period of several days.The de ated implant was
removed through the previous inframammary fold incisions. An open capsulotomy
around the entire base perimeter of the capsule was performed and another iden-
tical in atable saline implant was placed.
The patient is shown 1 month postoperatively.
SILICONE GEL–FILLED BREAST IMPLANTS
As previously mentioned, one of the complications of closed capsulotomy is im-
plant tear and gel extrusion. However, implants can also fail without a history of di-
rect trauma or manipulation.The effect that this free silicone gel has on women has
become one of the most widely publicized and scrutinized aspects of current plas-
tic surgery. A brief review is necessary to fully understand the signi cance.
Implant rupture during closed compression capsulotomy was first reported in
1977.55,56 The extent to which the silicone was extruded was anecdotally reported
by several authors who described silicone at distant sites including the axilla, upper
extremity, and groin.59-61

The rst reports of gel leakage unrelated to closed capsulotomy date back to 1978
when it was noted that there was spontaneous diffusion of silicone from implants
placed on cardboard.62 To prove that the gel-bleed phenomenon occurred in vivo,
the capsule around the implants was microscopically examined and found to have
silicone-laden histiocytes.63 A report from Austria the next year made the associa-
tion of leaking implants and lymphadenopathy.64 Manufacturers of silicone im-
plants continued to alter the design of the material to lessen the risk of leakage.The
rst-generation implants were composed of a rm gel with a thick elastomeric
wall, but because of high contracture rates in these implants, a second generation of
implants was introduced in 1972, which had a softer gel and a thinner wall. Despite
the change, surgeons observed greater rupture and bleed from them.63 The manu-
facturers responded with a number of third-generation implants after 1979, which
had a stronger shell and more cohesive gel ll.65
Reported rates of rupture have varied from 4% to 63%,3,66,67 with the large variation
in rate attributable to a lack of consensus on the de nition of “rupture.”66,68 Al-
though the gold standard for identifying implant rupture has traditionally been re-
moval and examination of the implants, the combined use of ultrasound and MRI
has increased the positive predictive value of these studies and has allowed for
greater than a 90% sensitivity in the diagnosis of rupture. Risk factors for breast
implant rupture have been identi ed as:older implants, retroglandular location, sig-
ni cant implant contracture, and presence of local symptoms.69
The IOM report67 stated that rupture rates reported in the medical literature across
studies ranged from 0.3% to 77%. This large range of rupture rates is the result of
different types and models of implant, varying durations of implantation, different
types of groups of women studied, and other factors. The IOM report also stated
that extracapsular gel (gel outside the brous capsule) was present in about 12% to
26% of gel- lled ruptures reported in the medical literature. The IOM estimated
that less than 10% of modern silicone gel– lled breast implants would have rup-
tured by 5 years, and that the rupture rate would continue to increase over time.
The FDA reported a retrospective study on the rupture of silicone gel– lled breast
implants.70 This study included patients who had undergone augmentation before
1988.Three hundred and forty-four women (with 687 implants) had an MRI ex-
amination of their breasts to determine whether there was evidence of rupture of
their implants. Of the 687 implants in the study, 378 implants (55%) were ruptured.
This means that 69% of the 344 women had at least one ruptured breast implant.
Of the 265 women with at least one rupture, 73 (21%) had extracapsular (outside
the capsule) silicone gel in one or both breasts. Factors that were associated with
rupture included the age of the implant, the speci c manufacturer of the implant,
and the surgical placement (submuscular versus subglandular) of the implant.
1287
Chapter 34
Reoperative Surgery Following Breast Augmentation

1288
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Marotta et al71 reviewed numerous publications on more than 9770 silicone im-
plants that were removed They concluded that 26% of implants were ruptured by
3.9 years, 47% were ruptured by 10.3 years, and 69% were ruptured by 17.8 years.
Marotta et al also reported that shells from removed silicone gel– lled breast im-
plants were considerably weaker than shells before implantation.
Holmich et al72 reported on a group of 271 women with 533 augmentation breast
implants, who had MRI evaluations for rupture.These women had breast implan-
tation before 1996 and were randomly selected from four plastic surgery clinics in
Denmark. The authors found that, overall, 26% of implants in 36% of the women
examined were found to be ruptured, and an additional 6% of implants were pos-
sibly ruptured.This is the minimum rupture rate for this group because there were
problems with performance of the MRI at one of the study sites. Of the ruptured
implants, 22% were extracapsular, and these ruptures were signi cantly associated
with a history of closed capsulotomy.
In a follow-up study by Holmich et al,73 this group of women had another MRI 2
years later. Over the 2-year period, the MRI evaluations showed that 17% of the
implants were de nitely or possibly ruptured.
According to the IOM report,67 the diagnosis of rupture of a silicone gel– lled
breast implant is important because the release of silicone gel and uid into the
tissues may result in local complications. An intracapsular rupture may become ex-
tracapsular, and it is generally recommended that both situations indicate the need
for implant removal. The rupture rate (both intracapsular and extracapsular) over
time of modern silicone gel– lled breast implants is currently not well character-
ized.The silent rupture rate over time is not known for modern silicone gel– lled
breast implants.
SILICONE-ASSOCIATED PROBLEMS
PATIENT EVALUATION
Plastic surgeons continue to speak with patients who are concerned about the
safety of breast implants. Many of these patients simply have questions regarding
their implants;others may have either local or systemic symptoms that they or their
physicians relate to their implants. A careful methodical approach to each of these
patients is warranted. A multidisciplinary team including the plastic surgeon,
rheumatologist, radiologist, and psychiatrist may be helpful under certain circum-
stances. None of these patients should ever be dismissed without a complete con-
sultation.
The majority of women who are currently returning for evaluation are primarily
concerned with two issues: whether their implants are intact and whether any lo-
cal or systemic symptoms they have been experiencing are related to their implants.

One of the primary roles of the plastic surgeon is to educate each pa-
tient on what is currently known or unknown from a scienti c stand-
point.
Each plastic surgeon caring for the patient who has undergone augmentation
mammaplasty must remain well-informed regarding ongoing scienti c studies and
recommendations from industry and government. Reassurance may be all that is
necessary for the otherwise entirely asymptomatic patient. Helping a woman sort
out what is fact from what is ction goes a long way toward this reassurance.
Although silicone gel implants may leak without producing any symptoms at all,
some patients will experience changes that might be associated with a leak. As
mentioned previously, the development of capsular contracture has been associated
with gel bleed or implant failure. A new onset of rmness, chest-wall discomfort,
or burning pain, which may radiate to the shoulder or around the chest wall, will
sometimes develop in the presence of a failed or failing implant. Similarly, a change
in the size or shape of an implant, particularly if unilateral, may be associated with
rupture.
For the sake of this chapter, a leak refers to an implant that has a small amount of
silicone gel on the outside of the silicone elastomer. This leak may be via either a
small pinhole or by gel bleed. A rupture or disrupted implant refers to one with a
larger tear in which a large amount or even the majority of gel is outside of a par-
tially or completely collapsed silicone elastomer. An intracapsular rupture is one in
which the gel is maintained within the capsule. An extracapsular rupturehas occurred
if the gel has migrated out of or has been forced through the capsule to appear in
breast tissue or beyond. Some patients may express a “feeling” that the implant has
ruptured and may relate this suspicion to a history of localized trauma.
Implant failure is dif cult to diagnose by simple physical examination.The edge of
the capsule should be carefully palpated for areas of irregularity or possible masses
within the capsule. Older well-established capsules may be calci ed, which may
account for irregularities. However, distinct nodules within the capsule may also
represent silicone granulomas or other benign masses. In addition, malignant disease
can present as a nodule within the capsule.
The breast parenchyma must be carefully examined to rule out other pathologic
conditions of the breast. Similarly, regional lymph nodes should be carefully pal-
pated for evidence of lymphadenopathy, which has been associated with implant
failure.
A lateral bulge is occasionally present in patients with a ruptured implant. It is most
easily visualized with the patient in the supine position.The bulge can be felt along
the lateral edge of the breast.
1289
Chapter 34
Reoperative Surgery Following Breast Augmentation

1290
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Patient Example
This patient had presented with a burning sensation around the right breast implant
that was associated with a bulge created by free silicone gel within the capsule.
At the time of implant removal, the inframammary incision was opened.The cap-
sule was quite thin and tore spontaneously, revealing the extruded gel. Large-bore
suction tubing that is used for suction lipectomy has been helpful in evacuating
free gel in these circumstances.This method of gel removal helps to prevent the gel
from contacting other dissected tissue planes.
The left breast implant was also removed, but it was intact. The left and right im-
plants are shown after removal. Saline implants were placed into the same pockets.

1291
Chapter 34
Reoperative Surgery Following Breast Augmentation
Indications for Radiologic Workup
Not every patient needs a radiologic workup because the results may have little
bearing on management decisions. In addition, any view of the implant is only a
“snapshot” in time.Therefore it is not practical or cost effective to routinely use ra-
diologic methods to screen patients with breast implants.
Each radiologic method is described in detail in Chapter 38. If a plastic surgeon has
access to good mammography, ultrasonography, and MRI, the decision as to which
technique to use may be deferred to the radiologist. Mammography is satisfactory
for detecting extracapsular rupture but is somewhat inaccurate for identifying leak-
ing or failed implants in the intracapsular space. Ultrasonography has been quite ef-
fective for evaluating masses alongside the capsule or within the breast parenchyma.
MRI has been the most helpful for detecting intracapsular leak or rupture but only
when used by experienced radiologists.
The starting point for a radiologic workup in women between 35 and 40 years of
age should be a baseline mammogram if they have not already had one. Often the
breast parenchyma can be screened and some information about the implant can be
obtained. An MRI scan may be recommended to evaluate the intracapsular status
of the implant.
The decision to perform radiologic tests is determined on an individual basis. A pa-
tient who is otherwise asymptomatic and does not wish to have the implants re-
moved needs no further workup. However, some patients will consider having their
implants removed if radiologic workup indicates a possible leak or failure. In this
case, because the results of an MRI scan will affect a patient’s decision, proceeding
with the examination is indicated. Women who have already decided to undergo
explantation do not need further radiologic studies except under special circum-
stances. For example, radiologic evaluation of extracapsular masses might help the
surgeon to determine whether the surgical removal of these masses should be per-
formed at the time of explantation.
Patients With Local Symptoms
Pain or discomfort in the area surrounding a breast implant, particularly one that
has been in place for many years, is common. Patients may describe a tightness that
is often related to capsular contracture. Other times the pain is localized to a rib or
a speci c area of the capsule. The causes of pain around an implant include neu-
roma, capsular contracture, in ammatory response from a leaking implant, or me-
chanical pressure from a large or heavy implant. Some local pain syndromes simply
cannot be accurately diagnosed.
If the patient is to be treated without surgery, certain types of brassiere support,
massage, and administration of antiin ammatory agents has been most helpful. Cos-
tochondritis, often caused by mechanical shearing, will also often respond to these
measures.

1292
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Chronic pain from capsular contracture or gel leak often improves after reoperative
surgery. In the case of contracture, capsulotomy or capsulectomy may offer relief.
If gel leak is the cause, the patient may bene t from implant removal or replace-
ment. However, improvement may be only temporary. Explantation with total cap-
sulectomy may be necessary for the patient who has debilitating local pain. Total
capsulectomy may sometimes provide pain relief by releasing constricting scar over
the chest wall or muscle.
Patient Example
This 45-year-old patient presented with pain and deformity surrounding her right
breast implant. Both a mammogram and MRI suggested intracapsular rupture.We
offered explantation and capsulectomy with silicone gel implant replacement in
the subpectoral position.
At the time of reoperation the right implant was completely ruptured but con-
tained within the contracted capsule.The left implant was intact.
Left
Right

Five years postoperatively, the patient continues to be symptom-free and satis ed
with the size and shape of her breasts.
Patients With Systemic Symptoms
Many patients who seek consultation with a plastic surgeon regarding their breast
implants also complain of a variety of systemic symptoms. It may be nearly impos-
sible to con rm that these symptoms are related to the breast implants. Some pa-
tients seem to have been in uenced by articles they have read or news stories they
have watched on television. Others have experienced a variety of vague systemic
complaints that they feel may be related to their implants. The most common
symptoms are fatigue, muscle and joint aches and pain, weakness, memory loss, skin
changes or rashes, and burning discomfort in the hands and feet.74-94
It is important to document each symptom a patient mentions regardless of
whether it can be logically attributed to the breast implant.We refer most patients
with systemic symptoms to a rheumatologist for further testing. A rheumatologic
workup includes a standardized questionnaire and laboratory evaluation consisting
of rheumatoid factor and antinuclear antibody, thyroid function tests, and a cy-
tokine pro le. In our experience most women with such symptoms have not had
systemic rheumatologic disorders such as scleroderma or systemic lupus erythe-
matosus. Some have had either bromyalgia or a type of soft tissue rheumatism at-
tributable to overuse syndromes. In some patients these symptoms have responded
to local steroid injections.
TREATMENT
Removal of Breast Implants
Every patient who returns for evaluation of their implants, even if symptomatic,
does not necessarily need an operation. Some women elect to have their implants
removed. Many of these patients have undergone augmentation in earlier years but
now have different motivations, priorities, and body habitus. Some have gained
weight, have more breast tissue, and believe that the removal of their implants can
1293
Chapter 34
Reoperative Surgery Following Breast Augmentation

1294
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
be performed without making the residual breasts disproportionately small. Other
women simply do not wish to “take a chance” that the implants might eventually
be shown unsafe and therefore want to have them removed.
In general, once a patient has been fully educated about what is known
and not known regarding breast implants and has made a decision to
have them removed, the role of the plastic surgeon should be to facil-
itate explantation.
Other than a patient’s fear of the implants, there are other reasons to consider re-
moval. Patients with known or suspected rupture should have implants removed or
replaced. Painful capsular contracture is best treated by total capsulectomy and im-
plant removal. Some patients have had poor surgical results as a result of poorly ex-
ecuted surgery. Others have capsular contracture, implant malposition, or continued
glandular ptosis with aging. Once the aesthetic results have become poor, both the
patient and surgeon will usually agree to implant removal with possible subsequent
reconstruction. Finally, breast cancer may develop in patients with implants; how-
ever, the rate is no greater than for the general population.95-97 Therefore the treat-
ment of breast cancer may include removal of the implant.
The following options are offered to most patients with breast augmentations who
are experiencing problems:(1) observation only, (2) removal of the implant with or
without capsulectomy, (3) removal of the implant with or without capsulectomy,
with saline implant replacement, (4) removal of the implant with or without cap-
sulectomy, with mastopexy.
Autogenous conversion using aps such as the transverse rectus abdominis myocu-
taneous (TRAM) or latissimus dorsi ap is rarely indicated for patients who had
their implants inserted for breast augmentation. These procedures have a prohibi-
tive risk and medical cost, making them impractical options for implant replace-
ment. A distant flap procedure is a reasonable reconstructive alternative only in
very rare circumstances (for example, if the patient has undergone multiple failed
implant procedures and is in a situation similar to that of a patient who has under-
gone subcutaneous mastectomy).
Is Total Capsulectomy Necessary?
There are very few if any absolute indications for total capsulectomy. However, to-
tal capsulectomy is often an easy way to extract the device without leaving resid-
ual silicone when trying to remove a ruptured implant. Established capsular con-
tracture is well-treated with capsulectomy, especially if the surgeon intends to
replace the implant with a textured-surface implant in which an interface with na-
tive tissue may prevent future capsular contracture. However, total capsulectomy is
not always a simple procedure and may result in additional morbidity, particularly
if the capsule is beneath the pectoralis major muscle and is dense and adherent to
the chest wall. Patients should be alerted to the fact that total capsulectomy may not

be safe under all circumstances and that sometimes breast and muscle tissue must be
sacri ced with this procedure, which can lead to additional bleeding and eventu-
ally to the thinning of the soft tissue coverage. If a patient speci cally requests to-
tal capsulectomy, we discuss these factors and let her know that we may decide in-
traoperatively to leave some intact capsule behind rather than create additional
morbidity.
Whether or not to perform total capsulectomy at explantation remains a controver-
sial issue among plastic surgeons. However, some patients have a great fear of sili-
cone and may insist that the entire capsule be removed. These patients must be
carefully counseled that although most of the visible silicone can be removed, mi-
croscopic particles will be left behind. Although the impact of this residual silicone
in the body is unknown as of this writing, it appears that MRI scanning will detect
any signi cant amount of silicone left behind. The presence of residual silicone
may serve as a possible source of confusion for patients concerned about the rela-
tionship between silicone and symptoms they might be experiencing. For example,
a patient with systemic symptoms may want her implants removed because she be-
lieves that her symptoms might be caused by or related to her implants. If her symp-
toms fail to substantially improve after explantation, she may wonder whether sil-
icone left behind in the capsule could be responsible for her lack of recovery, even
in the absence of scienti c data supporting such a contention. For this reason we
believe a concerted effort should be made to remove as much of the capsule as
possible in patients with systemic symptoms or ruptured implants.
Leaving the capsule behind, even parts of it, can also be a problem with screening
mammography results. Capsules containing calcium may cause confusion in inter-
preting results of future mammograms. In addition, residual capsules may result in
persistent postoperative seromas. We prefer to place a drain any time signi cant
surgery has been performed on a capsule.
Patients who undergo explantation of polyurethane-covered implants and capsulec-
tomy are treated in a similar fashion. However, this type of implant has several fea-
tures that require special attention. The polyurethane capsule may have become
separated from the inner implant, which occasionally results in uid accumulating
within this space. In addition, the capsule may be slightly thicker than that which
develops with silicone implants. By design the capsule grows within and among
the open-pore foam structure of the polyurethane coating.This intertwined growth
makes capsulectomy more dif cult. However, a plane of dissection can generally be
developed just outside the capsule and capsule removal accomplished using sharp
dissection.
Most explantation procedures are performed as an outpatient surgery.We prefer to
have the patient under general anesthesia. If a total capsulectomy is performed, we
prefer the inframammary approach. Usually the previous incision is satisfactory,
although it may need to be extended to allow adequate visualization to facilitate
dissection.
1295
Chapter 34
Reoperative Surgery Following Breast Augmentation

1296
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Patient Examples
This 38-year-old patient had undergone breast augmentation using subpectoral
smooth-surface silicone gel implants 8 years earlier. Although satis ed with the re-
sult, she developed intermittent muscular pain and weakness associated with fa-
tigue. Rheumatologic evaluation was most consistent with bromyalgia.The patient
showed only moderate improvement with exercise and antiin ammatory agents.
She strongly desired that her implants be removed.
In view of the patient’s concern about silicone and its relation to her symptoms, we
believed that capsulectomy was indicated. On removal both the right and left im-
plants appeared to be intact. The capsules were relatively thin. Histologically the
capsules showed multinucleated giant cells and foreign body reaction.

1297
Chapter 34
Reoperative Surgery Following Breast Augmentation
Postoperatively the aesthetic result was acceptable.The patient subjectively consid-
ered that her symptoms improved postoperatively. However, several months later
they returned.
Established capsular contracture is best treated using total capsulectomy. Whether
the patient wants to have the implants replaced is a matter of individual choice.
This patient presented 12 years after subglandular augmentation with silicone gel
breast implants. Firmness developed within the rst year postoperatively, and she
had undergone several previous attempts at closed capsulotomy many years before.
Her main reason for presentation was pain around the implants that extended into
the shoulders. In addition, she had fatigue and generalized weakness. She strongly
wanted her implants to be removed. Rheumatologic ndings were consistent with
bromyalgia. She was offered mastopexy but declined because she did not wish to
have additional scars.

1298
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Postoperatively the patient had complete relief of breast pain and discomfort. How-
ever, the weakness and fatigue have persisted.
Tenderness surrounding palpable silicone granulomas is an indication for total cap-
sulectomy and removal of the masses.This patient demonstrated established capsu-
lar contracture with silicone granulomas in the lateral chest wall as a result of im-
plant rupture.Treatment consisted of total capsulectomy and excision of the silicone
granulomas as marked. The postoperative result is shown. Unfortunately, local
symptoms persisted. She ultimately elected to have the saline implants removed as
well. Her symptoms have currently improved, but she is undergoing treatment in a
pain clinic for chronic pain in the lateral chest wall, shoulder, and right arm.

This patient was referred after undergoing a series of procedures. She had under-
gone transaxillary subglandular augmentation with smooth-surface silicone gel im-
plants several years before presenting to us. Postoperatively a left-sided hematoma
developed and was drained 1 month later. Capsular contracture developed 5 months
postoperatively on both sides and was treated by exchanging the smooth-surface
implants with subglandular polyurethane-covered implants. One month later, red-
ness developed beneath the left implant. Beginning 3 months later (9 months after
the original surgery), several regimens of antibiotic agents were administered over
the course of 3 months, and she had recurrent bouts of cellulitis and drainage. Fi-
nally, 14 months after augmentation procedure, the left polyurethane-covered im-
plant was removed. For the next 3 months, she developed multiple recurrent ab-
scesses of the left breast.When we rst saw the patient, purulent drainage continued
from the inframammary fold incision on the left side. She was presumed to have an
infected retained polyurethane capsule. Open capsulectomy was recommended.
1299
Chapter 34
Reoperative Surgery Following Breast Augmentation
After removal of the residual polyurethane, the wound was simply allowed to heal.
The plan was to wait for the breast to become soft, which ultimately occurred.

1300
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
We elected to wait a full 9 months before placing a tissue expander. At that time the
Becker expander-prosthesis was considered to be the best choice.
Gradual expansion was successful because the device was placed at the proper level.
This placement allowed the inframammary fold to develop in the correct position.
A small concentric periareolar mastopexy helped to improve the shape of the left
breast. However, the postoperative result re ects the difference in the shape of the
two implants. Replacement of the right polyurethane-covered implant with a
Becker expander-prosthesis identical to that used on the left side was recently per-
formed, resulting in improved symmetry.
This case demonstrates the importance of ensuring that adequate debridement of
the residual capsule is performed before another implant is inserted. Although these
patients may be frustrated and anxious to achieve the end result, the worst mistake
that a surgeon can make is to take shortcuts. It is imperative to ensure that infec-
tion has been adequately treated before a new implant is inserted. In retrospect,
this patient would have been well-served if the prosthesis and the infected capsule
had been removed at the rst sign of recurrent infection.

TREATMENT OF THE AGING AND
AUGMENTED BREAST
One of the more common types of patient we see are women who have had their
implants for many years and no longer need them, or wish to have their breasts re-
shaped.The sheer weight of an implant pressing against the breast tissue for many
years results in thinning, atrophy, and gradual ptosis. Further, many women experi-
ence a certain degree of weight gain as they enter the fourth and fth decades of
life. Although they may have had much smaller breasts earlier and bene ted by the
presence of implants, many women find that after fifteen or twenty years their
breasts are now larger than they wish them to be. It is rarely possible to simply re-
move the implants and still maintain an aesthetic shape. Therefore some form of
mastopexy is often bene cial.
Patients who have postaugmentation ptosis or who view their breasts as being too
large, have three treatment options. First, the implants can be simply removed. If the
patient has saline implants and is considering either additional implants or a
mastopexy, a simple technique could help them decide whether they will be large
enough. In this technique, shown in the following photographs, the saline implants
are percutaneously emptied in the of ce.
1301
Chapter 34
Reoperative Surgery Following Breast Augmentation
A small amount of local anesthetic is in ltrated in the lower pole of the breast as the
implant is pressed downward. An 18-gauge needle is inserted directly through the
lower pole into the implant and hooked up to suction tubing. The saline is com-
pletely extracted.
The second option available to the patient is to electively undergo explantation
and mastopexy. If the preoperative de ation described previously has been accom-
plished, we give the patient approximately 1 month to allow the tissues to contract
and become rm. During this time, the patient can decide if she has adequate vol-
ume, in which case she may choose to only undergo mastopexy without an addi-
tional implant.

1302
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
This 35-year-old patient had large breast implants placed 12 years earlier in an at-
tempt to treat early ptosis. Gradually the ptosis worsened and she presented re-
questing correction.
The operative plan was to exchange her implants from the subglandular to the sub-
pectoral position and to perform a vertical mastopexy.

A segment of capsule from the undersurface of the superiorly based parenchymal
ap was used to support the implant underneath the pectoral muscle, thus prevent-
ing it from sliding inferolaterally.The superiorly based parenchymal ap was turned
beneath the upper pole to provide additional fullness.
1303
Chapter 34
Reoperative Surgery Following Breast Augmentation

1304
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The medial and lateral pillars were adjusted for optimal shape. The lower pole
should initially appear attened.The nipple-areola was then sited, nal closure was
performed, and a Tegaderm dressing was placed.
The patient is shown 3 years postoperatively.

REOPERATIVE CHALLENGES
DOUBLE-BUBBLE DEFORMITY
Patient Example
1305
Chapter 34
Reoperative Surgery Following Breast Augmentation
This 22-year-old patient had previously undergone subpectoral saline augmenta-
tion. Gradually she developed deformity of the left breast. It appeared as if the im-
plant had slipped beneath the native inframammary fold, causing as double-bubble
deformity. Correction was accomplished by restoring the stability of the inframam-
mary fold through an internal capsular plication technique depicted previously.
The postoperative correction has remained stable for 3 years.

1306
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
SALINE IMPLANT DEFLATION W ITH PTOSIS
This 34-year-old patient presented with a partial right saline implant de ation 5
years after breast augmentation. She had developed additional breast ptosis after
pregnancy and desired correction.
The surgical correction required replacement of both saline implants and a verti-
cal mastopexy with a superiorly based parenchymal flap rotated into the upper
pole. Shape correction has remained stable 6 months postoperatively.

CAPSULAR CONTRACTURE OF SALINE IMPLANT W ITH
PERIAREOLAR MASTOPEXY DEFORMITY
1307
Chapter 34
Reoperative Surgery Following Breast Augmentation
This 24-year-old patient was referred after bilateral augmentation with periareolar
mastopexy. A second procedure had also been performed to try to elevate the left
side by placing larger implants. To “make sense” of the deformity, we elected to
proceed with percutaneous saline de ation in the of ce as described previously.
After saline implant de ation the parenchymal volumes appear roughly equivalent,
with the nipple position much more symmetrical. The operative plan was to re-
move the implants from the subpectoral plane and place smaller textured silicone
gel implants in the subglandular plane with a vertical mastopexy.

1308
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The postoperative result at 3 months demonstrates considerable improvement in
shape and symmetry.
AUTOAUGMENTATION USING R EVERSE ABDOMINOPLASTY
TECHNIQUE
This 42-year-old patient was self-referred after undergoing large saline implant
breast augmentation and mastopexy to treat breast ptosis. She had undergone three
previous procedures in which larger implants were placed to try to “ ll up the skin
envelope.” As a result her breasts were much larger and lower than desired, and she
felt that her superior abdominal wall was lax. The patient was offered preliminary
saline implant de ation in the of ce to be followed by autoaugmentation using a
reverse abdominoplasty technique.
Thirty days after de ation, the patient had an opportunity to determine her opti-
mal breast volume.

The sequence above demonstrates the technique of transposing superiorly based
deepithelialized fat aps into the subglandular plane with an inverted-T closure.
Approximately 125 g of tissue were available for the augmentation.
1309
Chapter 34
Reoperative Surgery Following Breast Augmentation

1310
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The patient is shown 3 months postoperatively. The size and shape of the breasts
were satisfactory without the use of breast implants.The abdomen was improved.
CONCLUSION
Of all the reoperative conditions discussed in this book, none has undergone such
a radical evolution in the past 2 years as conditions regarding patients with breast
implants.The foregoing discussion represents our current approach to patients with
a variety of reoperative conditions. Research studies continue to establish the safety
and ef cacy of both silicone gel and saline breast implants. New products are also be-
ing developed.The results of these studies will impact the future surgical manage-
ment of women with breast implants. It follows that reoperation for these types of
problems will also change, particularly indications and techniques. Hopefully, with
improved devices, patient satisfaction will remain high and reoperative intervention
can be kept to a minimum.

References—With Key Annotated References
1. Estes EH Jr. Breast implants (Resolution 259, A-91). Report of the Council on Scienti c Af-
fairs, Report M(I-91), Dec 1991.
2. Hetter GP. Satisfactions and dissatisfactions of patients with augmentation mammaplasty. Plast
Reconstr Surg 64:151, 1979.
3. Gabriel SE,Woods JE, O’Fallon WM, et al. Complications leading to surgery after breast im-
plantation. New Engl J Med 336:679, 1997.
4. Patient Labeling for Inamed Saline Breast Implants, 2004.
Available at http:// cdrh/ breastimplants/ .
5. Patient Labeling for Mentor Saline Breast Implants, 2004.
Available at http:// cdrh/ breastimplants/ .
6. Brown SL, Pennello G. Replacement surgery and silicone gel breast implant rupture: Self-
report by women after mammoplasty. J Womens Health Gend Based Med 11:255, 2002.
A summary of the ndings of this study is also available on FDA’s website at
http:// cdrh/ breastimplants/ .
7. Maliniac JW. Arterial blood supply of the breast. Arch Surg 47:329, 1943.
8. Bostwick J III. Plastic and Reconstructive Surgery of the Breast. St Louis: Quality Medical
Publishing, 1990.
9. Shapiro MA.The nipple-areola and mammary blood supply. Plast Reconstr Surg 78:129, 1976.
10. Courtiss EH, Goldwyn RM. Breast sensation before and after plastic surgery. Plast Reconstr
Surg 58:1, 1976.
11. Goldwyn RM. Plastic and Reconstructive Surgery of the Breast. Boston: Little Brown, 1976.
12. Peck GC. Complications and Problems in Aesthetic Plastic Surgery. New York: Gower Med-
ical Publishing, 1992.
13. Gurdin M. Complications of breast augmentation. Plast Reconstr Surg 40:530, 1967.
14. Burkhardt RB, Dempsey PD, Schnur PL, et al. Capsular contracture: A prospective study of
the effect of local antibacterial agents. Plast Reconstr Surg 77:919, 1986.
15. Brownstein ML, Owsley JQ Jr. Augmentation mammaplasty: A survey of major complica-
tions. In Owsley JQ, Peterson RA, eds. Symposium on Aesthetic Surgery of the Breast. St
Louis: Mosby, 1978, p 267.
16. Courtiss EH, Goldwyn RM, Anastasi GW.The fate of breast implants with infections around
them. Plast Reconstr Surg 63:812, 1979.
17. McGrath MH, Burkhardt BR. The safety and ef cacy of breast implants for augmentation
mammaplasty. Plast Reconstr Surg 74:550, 1984.
18. Toranto IR, Malow JB. Atypical mycobacterial periprosthetic infections—Diagnosis and treat-
ment. Plast Reconstr Surg 66:226, 1980.
19. LeRoy J, Given KS.Wound infection in breast augmentation:The role of prophylactic periop-
erative antibiotics. Aesthetic Plast Surg 15:303, 1991.
20. Barnett A, Lavey E, Peall RM, et al.Toxic shock syndrome from an infected breast prosthesis.
Ann Plast Surg 10:408, 1983.
21. Georgiade NG. Aesthetic Surgery of the Breast. Philadelphia:WB Saunders, 1990.
22. Clarendon CD. Implant descent: A complication of augmentation mammaplasty and its cor-
rection. Ann Plast Surg 21:452, 1988.
23. Biggs T, Cukier J,Worthing L. Augmentation mammaplasty: A review of eighteen years. Plast
Reconstr Surg 69:445, 1982.
24. Kossovsky N, Heggers JP, Parsons RW, et al. Acceleration of capsule formation around silicone
implants by infection in a guinea pig model. Plast Reconstr Surg 73:91, 1984.
25. Gayou RM. A histologic comparison of contracted and noncontracted capsules around silicone
breast implants. Plast Reconstr Surg 63:700, 1979.
26. Rudolph R, Abraham J,Vecchione T, et al. Myo broblasts and free silicone around breast im-
plants. Plast Reconstr Surg 62:185, 1978.
1311
Chapter 34
Reoperative Surgery Following Breast Augmentation

1312
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
27. Hipps CJ, Raju DR, Straith RE. In uence of some operative and postoperative factors on cap-
sular contracture around breast prostheses. Plast Reconstr Surg 61:384, 1978.
28. Williams C, Aston S, Rees TD. The effect of hematoma on the thickness of pseudosheaths
around silicone implants. Plast Reconstr Surg 56:194, 1975.
29. Caffee HH.The effects of hematoma on implant capsules. Ann Plast Surg 16:102, 1986.
30. Shah Z, Lehman JA, Tan J. Does infection play a role in breast capsular contracture? Plast
Reconstr Surg 68:34, 1981.
31. Birnbaum LM, Hopp DD, Mertens BE.The role of iodine-releasing silicone implants in pre-
vention of spherical contractures. Plast Reconstr Surg 69:956, 1982.
32. Dubin DB. The etiology, pathophysiology, predictability, and early detection of spherical scar
contracture of the breast: A detailed explanation and protocol for prevention of spherical scar
contracture of the breast. Presented at the Thirteenth Annual Meeting of the American Soci-
ety of Aesthetic Plastic Surgery, Orlando, May 1980.
33. Burkhardt BR, Dempsey PD, Schnur TL, et al. A prospective study of the effect of local anti-
bacterial agents. Plast Reconstr Surg 77:919, 1986.
34. Domanskis EJ, Owsley JQ. Histological investigation of the etiology of capsule contracture
following augmentation mammaplasty. Plast Reconstr Surg 58:689, 1976.
35. Asplund O. Capsule contracture and silicone gel and saline- lled breast implants after recon-
struction. Plast Reconstr Surg 73:270, 1984.
36. Caffee HR. The in uence of silicone bleed on capsule contracture. Ann Plast Surg 17:284,
1986.
37. Broadbent TR,Woolf RM. Augmentation mammaplasty. Plast Reconstr Surg 40:517, 1967.
38. Burkhardt BR. Comparing contracture rates:Probability theory and the unilateral contracture.
Plast Reconstr Surg 74:527, 1984.
39. McKinney P,Treslie G. Long-term comparison of patients with gel and saline mammary im-
plants. Plast Reconstr Surg 72:27, 1983.
40. Caffee HH.Textured silicone and capsule contracture. Ann Plast Surg 24:197, 1990.
41. Eyssen JE, von Werssowetz AJ, Middleton GD. Reconstruction of the breast using polyurethane
coated prostheses. Plast Reconstr Surg 73:415, 1984.
42. Rudolph R. Submuscular vs submammary placement of breast prostheses. Presented at the
Thirtieth Annual Meeting of the Plastic Surgery Research Counsel, Portland, OR, 1985.
43. Mahler D, Hauben DJ. Retromammary vs retropectoral breast augmentation: A comparative
study. Ann Plast Surg 8:370, 1982.
44. Slade CL. Subcutaneous mastectomy: Acute complications and long-term follow-up. Plast
Reconstr Surg 73:84, 1984.
45. Caffee HH. Breast implant capsule contracture. Unpublished data, 1987.
46. Terino E. Essential concepts in prosthetic plastic surgery. Aesthetic Plast Surg 626:25, 1982.
47. Finnick CA. Spherical contracture of fibrous contracture around breast implants. Plast
Reconstr Surg 58:555, 1976.
48. Marshall WR. Amelioration of capsular contracture by motion restriction. Ann Plast Surg
16:211, 1986.
49. Stephens FO, Dunphy JE, Hunt KK. Effect of delayed administration of corticosteroids on
wound contraction. Ann Surg 173:214, 1971.
50. Peterson HD, Burt GB Jr. The role of steroids in prevention of circumferential capsular scar-
ring in augmentation mammaplasty. Plast Reconstr Surg 54:28, 1974.
51. Perrin ER. The use of soluble steroids within in atable breast prosthesis. Plast Reconstr Surg
57:163, 1976.
52. Cohen IK, Carricco TJ. Capsular contracture and steroid-related complications in augmenta-
tion mammaplasty. Aesthetic Plast Surg 4:267, 1980.
53. O’Neal RM, Argenta LC. Late side effects related to in atable breast prostheses containing
soluble steroids. Plast Reconstr Surg 69:641, 1982.
54. Little G, Baker JL. Result of closed compression capsulotomy for treatment of contracted breast
implant capsules. Plast Reconstr Surg 65:30, 1980.

55. Feliberti MD, Arrillage A, Colon GA. Rupture of in ated breast implants in closed compres-
sion capsulotomy. Plast Reconstr Surg 59:848, 1977.
56. Eisenberg HV, Bartels RJ. Rupture of a silicone bag-gel breast implant by closed compression
capsulotomy: Case report. Plast Reconstr Surg 59:849, 1977.
57. McKinney P,Treslie G. Long-term comparison of patients with gel and saline mammary im-
plants. Plast Reconstr Surg 72:27, 1983.
58. Derman GH, Argenta LC, Grabb WC. Delayed extrusion of in atable breast prostheses. Ann
Plast Surg 10:154, 1983.
59. Huang TT, Blackwell SJ, Louis SR. Migration of silicone gel after the “squeeze technique” to
rupture a contracted breast capsule: Case report. Plast Reconstr Surg 61:277, 1978.
60. Capozzi A, Du Bou R, Pennisi VR. Distant migration of silicone gel from a ruptured breast
implant. Plast Reconstr Surg 62:302, 1978.
61. Edmond J, Versaci A. Late complication of closed capsulotomy of the breast. Plast Reconstr
Surg 66:478, 1980.
62. Bergman RB, Van Der Ende AE. Exudation of silicone through the envelope of gel-filled
breast prostheses: An in vitro study. Br J Plast Surg 32:31, 1979.
63. Barker DE, Ritsky MI, Schultz S. Bleeding of silicone from the bag-gel breast implants and its
clinical relation to brous capsule reaction. Plast Reconstr Surg 61:836, 1978.
64. Whintsch W. Leaking Ashley prosthesis with lymphadenopathy. Presented at the Fifth Alpine
Workshop on Plastic and Reconstructive Surgery, Austria, Feb 1978.
65. Peters W, Smith D, Lugowski S. Failure properties of 352 explanted silicone-gel breast im-
plants. Can J Plast Surg 4:55, 1996.
66. Robinson OG, Bradley EL, Wilson DS. Analysis of explanted silicone implants: A report of
300 patients. Ann Plast Surg 34:1, 1995.
67. Institute of Medicine National Academy Press,Washington, DC,2000. Safety of Silicone Breast
Implants. IOM Report. Available at
68. Netscher DT, Walker LE, Weizer F, et al. A review of 198 patients (389 implants) who had
breast implants removed. J Long Term Eff Med Implants 5:11, 1995.
69. Feng LJ, Amini SB. Analysis of risk factors associated with rupture of silicone gel breast im-
plants. Plast Reconstr Surg 104:955, 1999.
Patients undergoing implant removal by a single surgeon between 1990 and 1996 were examined
for rupture and for 16 potential risk factors.The association between rupture and various factors was
studied using univariate and multivariate analyses. Eight hundred and forty-two patients underwent
removal of 1619 implants and signi cant risk factors for breast implant rupture were identi ed:older
implants, retroglandular implant location, implant contracture, local symptoms, certain implant type,
and certain manufacturer.
70. Brown SL, Middleton MS, Berg WA, et al. Prevalence of rupture of silicone gel breast im-
plants revealed on MR imaging in a population of women in Birmingham, Alabama. Am J
Roentgenol 175:1, 2000. A summary of the findings of this study is also available at
http:// cdrh/ breastimplants/ .
71. Marotta JS, Goldberg EP, Habal MB, et al. Silicone gel breast implant failures: Evaluation of
properties of shells and gels for explanted prostheses and meta-analysis of literature rupture
data. Ann Plast Surg 49:227, 2002.
72. Holmich LR, Kjoller K,Verjorg I, et al. Prevalence of silicone breast implant rupture among
Danish women. Plast Reconstr Surg 108:848, 2001.
73. Holmich LR, Friis S, Fryzek JP, et al. Incidence of silicone breast implant rupture. Arch Surg
138:801, 2003.
74. Schusterman MA, Kroll SS, Reece GP, et al. Incidence of autoimmune disease after breast re-
construction with silicone gel implants vs autogenous tissue: A preliminary report. Ann Plast
Surg 31:1, 1993.
75. Bridges AJ, Conley C, Wang G, et al. A clinical and immunologic evaluation with silicone
breast implants and symptoms of rheumatic disease. Ann Intern Med 118:929, 1993.
76. Sanchez-Guerrero J, Colditz GA, Karlson EW, et al. Silicone breast implants and the risk of
connective-tissue diseases and symptoms. N Engl J Med 332:1666, 1995.
1313
Chapter 34
Reoperative Surgery Following Breast Augmentation

1314
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
77. Ferguson JH. Silicone breast implants and neurologic disorders. Report of the Practice Com-
mittee of the American Academy of Neurology. Neurology 48:1504, 1997.
78. Winther JF, Bach FW, Friis S, et al. Neurologic disease among women with breast implants.
Neurology 50:951, 1998.
Using the Danish National Register of Patients, two cohorts of patients were evaluated for the pres-
ence of neurologic diseases: 1135 women who received cosmetic silicone breast implants, and 7071
women who had breast reduction surgery. Results indicated that relative to the comparison cohort,
women with implants had no excessive levels of de nite neurologic disease. Furthermore, medical
record reviews revealed that the majority of women with implants who were discharged with a neu-
rologic diagnosis had either symptoms before implant surgery or neurologic symptoms secondary to de-
generative diseases.
79. Brown SL, Pennello G, Berg WA, et al. Silicone gel breast implant rupture, extracapsular sili-
cone, and health status in a population of women. J Rheumatol 28:996, 2001.
80. Bondurant S, Ernster V, Herdman R. Safety of silicone breast implants:Report of the Commit-
tee on the Safety of Silicone Breast Implants (IOM). Washington, DC: National Academy
Press, 2000.
81. Independent Review Group—J Rogers Associates. Silicone gel breast implants:The Report of
the Independent Review Group. Cambridge, England: Crown, 1998.
82. Janowsky EC, Kupper LL, Hulka BS. Meta-analyses of the relation between silicone breast im-
plants and the risk of connective tissue diseases. N Engl J Med 342:781, 2000.
This article presents (1) a metaanalysis of the largest group of studies to date investigating the pos-
sible relationship between silicone breast implants and the risk of autoimmune conditions or connec-
tive-tissue diseases and (2) an evaluation of the public health effect of silicone breast implants by es-
timating the annual number of new cases of connective-tissue disease that can be attributed to the
presence of breast implants.The study provides no evidence in either the analysis of unadjusted odds
ratios or the analysis of adjusted relative risks of a signi cantly increased risk of any speci c connec-
tive-tissue disease, of all de nite connective-tissue diseases combined, or of any other autoimmune or
rheumatic conditions.
83. Tugwell P,Wells G, Peterson, et al. Do silicone breast implants cause rheumatologic disorders?
A systematic review for a court-appointed national science panel. Arthritis Rheum 44:2477,
2001.
84. Nyren O,Yin L, Josefsson S, et al. Risk of connective tissue disease and related disorders among
women with breast implants: A nation-wide retrospective cohort study in Sweden. Br Med J
316:417, 1998.
85. Kjoller K, Friis S, Mellemkjaer L, et al. Connective tissue disease and other rheumatic condi-
tions following cosmetic breast implantation in Denmark. Arch Intern Med 161:973, 2001.
86. Jensen B, Bliddal H, Kjoller K, et al. Rheumatic manifestations in Danish women with silicone
breast implants. Clin Rheumatol 20:345, 2001.
87. Wolfe F, Anderson J. Silicone lled breast implants and the risk of bromyalgia and rheuma-
toid arthritis. J Rheumatol 26:2025, 1999.
To test the hypothesis that silicone breast implants might be causally related to the development of -
bromyalgia, implantation status was determined in 464 patients with RA, 508 with bromyalgia,
261 with osteoarthritis (OA) of the knee or hip, and in 503 randomly selected community controls.
The temporal relationship from implantation to onset of bromyalgia and RA was investigated. No
relationship between prior silicone breast implants and the subsequent development of bromyalgia or
RA was noted. But implants appear to be more common in patients with than in patients without
bromyalgia. A common and predisposing set of psychosocial characteristics may be shared between pa-
tients who have bromyalgia and patients who undergo silicone breast implants.
88. Lai S, Goldman JA, Child AH, et al. Fibromyalgia, hypermobility, and breast implants. J
Rheumatol 27:2237, 2000.
89. Breiting VB, Holmich LR, Brandt B, et al. Long-term health status of Danish women with sil-
icone breast implants. Plast Reconstr Surg 114:217, 2004.
90. Brown SL, Pennello G, Berg WA, et al. Silicone gel breast implant rupture, extracapsular sili-
cone, and health status in a population of women. J Rheumatol 28:996, 2001.

91. Holmich LR, Kjoller K, Fryzek JP, et al. Self-reported diseases and symptoms by rupture sta-
tus among unselected Danish women with cosmetic silicone breast implants. Plast Reconstr
Surg 111:723, 2003.
92. Englert H, Joynar E, McGill N, et al.Women’s health after plastic surgery. Intern Med J 31:77,
2001.
93. Fryzek JP, Signorello LB, Hakelius L, et al. Self-reported symptoms among women after cos-
metic breast implant and breast reduction surgery. Plast Reconstr Surg 107:206, 2001.
94. Laing TJ, Schottenfeld D, Lacey JV, et al. Potential risk factors for undifferentiated connective
tissue disease among women: Implanted medical devices. Am J Epidemiol 154:610, 2001.
95. Deapen DM, Pike FC, Casagrande JT, et al. The relationship between breast cancer and aug-
mentation mammaplasty: An epidemiologic study. Plast Reconstr Surg 77:361, 1986.
96. Kern KA, Flannery JT, Kuehn PG. Carcinogenic Potential of silicone breast implants:A Con-
necticut statewide study. Plast Reconstr Surg 100:737, 1997.
To clarify the carcinogenic potential of silicone breast implants, 680 implant procedures performed on
women in Connecticut with no prior history of cancer were correlated with the subsequent develop-
ment of primary breast and nonbreast cancers. Neoplastic events after the placement of silicone breast
implants during a 13-year interval were quanti ed using a retrospective, linked-registry method.
Compared with the control group, the implant group demonstrated lower rates of breast cancer and
nonbreast cancer, leading the authors to conclude that silicone breast implants are not carcinogenic.
97. Gabriel SE, O’Fallon WM, Kurland LT, et al. Risk of connective tissue diseases and other dis-
orders after breast implantation. N Engl J Med 330:1697, 1994.
1315
Chapter 34
Reoperative Surgery Following Breast Augmentation

1316
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
1. A patient calls you the night after her breast augmentation, concerned that one
side is larger, bluish in color, and painful? The diagnosis is:
a. Acute seroma
b. Hematoma
c. Strep infection
d. Spontaneous saline autoin ation
e. Probable neuroma
2. The most reliable method to treat implant infection is:
a. An intravenous antibiotic agent administration in the hospital
b. Outpatient intravenous antibiotic therapy
c. Removal of the implant
d. Irrigation catheters, administration of an intravenous antibiotic agent, and
hospitalization to preserve the device
e. Aspiration of periimplant uid, culture, and oral antibiotic agents
3. All of the following are acceptable methods of treating implant malposition
except:
a. Compression band
b. Capsulotomy
c. Capsulorrhaphy
d. Implant-site change
e. Periareolar purse-string
4. Patients with old silicone gel implants who have multiple systemic symptoms
that they relate to their implants should:
a. Undergo psychiatric evaluation
b. Undergo a thorough rheumatologic workup
c. Have their implants removed and replaced with new-generation silicone
gel
d. Have their implants removed and replaced with saline implants
e. Have their implants removed with capsulectomy if ruptured and no re-
placement
5. The best rationale for removal of a breast implant capsule would be:
a. Ruptured silicone gel
b. Thickening that needs debulking
c. Calci cation
d. To improve mammography
e. To allow a new implant breast interphase to develop
R EVIEW QUESTIONS

1317
Reoperation Following
Implant Breast Reconstruction
James C. Grotting
C ha pter 3 5
Reoperative Problems
Inframammary fold
Capsular contracture
Hematoma
displacement
Flap failure
Seroma
Lack of projection
Implant de ation
Skin loss
Implant malposition
Gel leakage
Valve leakage
Chronic pain
Infection
Tumor recurrence
By three methods we may learn wisdom:
rst, by re ection, which is noblest;
second, by imitation, which is easiest;
third, by experience, which is the bitterest.
Confucius
The earliest attempts at breast reconstruction consisted of the simple placement
of some type of ller material to construct a mound. Although today these early re-
constructive efforts appear rudimentary at best, they laid the groundwork for the
development of newer and better techniques for breast reconstruction, acceptance
of breast reconstruction as an integral part of the breast cancer patient’s rehabilita-
tion, and inclusion of the plastic surgeon as a member of the breast cancer team. As
a specialty, we are indebted to these surgeons and patients who embarked on this
surgical adventure, paving the way for those of us who have followed.1-5

1318
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
However, the evolution of implant breast reconstruction is by no means concluded,
and with the new generation of saline as well as silicone gel– lled implants that
have been the mainstay of reconstruction over the past 30 years, there is renewed
interest in producing a permanent satisfactory breast mound without the use of
autogenous tissue. Nevertheless, women who have previously undergone implant
breast reconstruction and who return with new problems may require a change in
reconstructive approach.
Tissue expanders have also undergone technologic improvements.6-10 We now have
the ability to produce differential expansion of the chest wall to better match un-
altered opposite breast shapes. Incorporated valves have reduced valve-related mal-
functions. Textured surfaces permit a softer expandable capsule, and combination
devices (adjustable implants or expander-implant designs) have allowed single-stage
reconstruction, particularly in the bilateral patient.11-13
The goal of breast reconstruction is to produce a permanent, natural, and symmet-
rical match to the opposite breast, if present. No surgeon can hope to always
achieve perfect results in one operation. Staged procedures and secondary opera-
tions are often necessary, even commonplace, to perform re nements and to cor-
rect problems, particularly as more and more women with “state-of-the art” re-
constructions from decades earlier return to discuss the possibility of improvement.
We now have a variety of reliable techniques for treating patients with problems re-
lated to previous breast implant reconstructions.14-16
STAGED BREAST RECONSTRUCTION
The majority of breast reconstructions remain staged procedures. Usually the sec-
ond stage of an implant reconstruction can be accomplished as an outpatient pro-
cedure. I prefer to perform such surgery with the patient under general anesthesia,
because I believe it is more comfortable for the patient and gives me the option of
doing more extensive capsular surgery and adjustment of the fold area if necessary.
Secondary breast reconstruction requires a motivated patient and an experienced
and careful surgeon. Realistic expectations are the key to eventual patient satisfac-
tion. From the time of the rst consultation, the patient and her family should have
a clear view of the sequence of the operations and the time required to complete
the reconstruction.
TIMING
Various factors affect timing in a staged breast reconstruction. In immediate recon-
struction an expander is often placed at the initial procedure. However, a second-
stage reconstruction may need to be deferred until after the patient has completed
chemotherapy. This variable must be carefully explained to the patient in advance
of the reconstruction. Another factor that in uences the timing of the second stage

1319
Chapter 35
Reoperation Following Implant Breast Reconstruction
is the rate at which the skin envelope matures. Although maturity of the skin en-
velope predictably occurs 2 to 3 months postoperatively, in some patients factors
such as capsular contracture, persistent edema, or even radiation may delay the re-
turn of pliability to the soft tissues overlying the expander. I prefer to wait until the
skin envelope matures before I reoperate.
The increased use of postmastectomy radiation therapy has become an important
factor in uencing both technique choice and timing.17-22 Unfortunately, it is not al-
ways known in advance of the mastectomy which patients will subsequently un-
dergo radiation therapy.23,24 Because of the potential deleterious effects of radia-
tion on the eventual aesthetic result, careful consideration must be given as to
whether to attempt immediate reconstruction versus waiting until radiotherapy has
been completed.25 There are two potential problems associated with placement of
tissue expanders at the time of mastectomy in patients who subsequently undergo
radiotherapy. First, the presence of an expander may impact the successful delivery
of the radiation therapy. Second, the ultimate aesthetic outcome may be signi -
cantly impaired because of the prolonged effect of radiation on the soft tissues.To
address the rst concern, some radiotherapists prefer to have the expander de ated
during the radiation treatments.26 We always try to reach full expansion before the
patient undergoes radiotherapy. Even if the expander will ultimately be removed
and replaced with autogenous tissue, the expanded skin envelope may be able to be
preserved if it ultimately has satisfactory color and texture.
Our experience with postmastectomy radiotherapy has been that no matter what
type of reconstruction is performed immediately, radiotherapy never improves the
aesthetic result. For this reason, we now prefer to delay any type of reconstruction
until the radiotherapy has been completed. In fact, we will almost always wait 6
months to a year following the completion of radiotherapy to begin the recon-
struction and favor the use of autogenous tissue.
Another concept that has been developed to address the issue of uncertainty regard-
ing postmastectomy radiation therapy has been called delayed/ immediate reconstruc-
tion.26,27 In this technique, a temporary tissue expander is placed at the time of mas-
tectomy to preserve the valuable breast skin. The expander is left in place until a
de nitive decision regarding the use of radiation therapy can be made. For patients
who do not require radiotherapy, de nitive breast reconstruction is then performed
within 2 weeks of the mastectomy. This avoids delay in the start of adjuvant
chemotherapy and minimizes restrictive capsule formation around the temporary
expander. Autogenous tissue or a permanent implant can be used.28
PLANNING
Whether an expander or an implant was placed at the initial stage in a staged im-
plant reconstruction, the second stage of mound reconstruction will usually require
removal and replacement of the device. Perfect reconstructed symmetry with im-

1320
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
plant devices in a single stage is usually possible only in bilateral mastectomies or in
the case of a round nonptotic breast on the opposite side. Even in these instances,
the likelihood of reaching ideal symmetry in a single stage is quite low.
In recent years tissue expander technology has been developed to in uence the
quality of the expanded envelope and the shape. The choice of device is almost
entirely dependent upon the size and shape of the opposite breast. Still, the best re-
sults of expander or implant reconstruction are seen in bilateral mastectomy cases.
For unilateral reconstruction, the best results are seen in patients who are of normal
weight and have a rounded, nonptotic breast on the opposite side. The size and
shape of the tissue expander to be used on the reconstructive side is determined
through measurements of the normal side. Factors such as chest wall height, upper
pole fullness, base width of the opposite side, and degree of ptosis all in uence ex-
pander selection. In most patients, the majority of the expansion is required in the
lower pole. Low height semicircular expanders have been developed for just this
purpose (Mentor 6100 and Inamed 133LV).
The use of templates simpli es the measurement process.

1321
Chapter 35
Reoperation Following Implant Breast Reconstruction
Mirror-image expander placement in bilateral reconstruction virtually guarantees
symmetry in patients in whom the quantity and quality of skin coverage is identi-
cal.This patient presented 2 years after undergoing bilateral modi ed radical mas-
tectomies for carcinoma of the breast. Remote-valve adjustable implants were
placed through short incisions in the lateral mastectomy scars.6 The pockets were
submuscular in the upper portion and subcutaneous inferiorly and over the ser-
ratus anterior muscle. With the inframammary folds set at the proper position,
symmetrical expansion was accomplished, thereby simplifying the secondary pro-
cedure, which involved only nipple reconstruction and valve removal. The post-
operative result is shown at 1 year. More often, some alteration of the capsule is
necessary at the time of implant placement.
Currently there is considerable pressure from insurance companies and other pay-
ors to minimize secondary surgeries or eliminate them as a patient bene t.There-
fore proper planning becomes imperative to optimize results in as few procedures
as possible. Care in selecting the proper expander and positioning it at the right
level so that the inframammary fold develops symmetrically are key factors in min-
imizing the complexity of secondary revisions.

1322
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
However, planning errors do occur.27 Although such errors are easy to recognize in
retrospect, unfortunately they are not always easy to accept. One of the most dif -
cult discussions to have with a patient is to honestly explain that things have not
worked out according to plan and that a new tack must be taken. Remarkably, the
patient is often well aware of this even before the surgeon.With experience comes
the judgment of how tissues will respond to an implanted device or a tissue trans-
fer. Proper patient selection then becomes the key, thereby diminishing the require-
ment for reoperative adjustment or completely “changing course.”
The need to completely change course is effectively demonstrated in this patient,
who sought consultation after having undergone several previous reconstructive
procedures. Her history included multiple silicone injections for breast enlarge-
ment, which resulted in painful, contracted, and nodular breasts. She underwent
subcutaneous mastectomy and reconstruction using tissue expanders. Apparently
these expanders became exposed as a result of skin loss and super cial infection. She
is shown preoperatively with the expanders still in place. Clearly, implant recon-
struction did not produce the desired result. Therefore we elected to completely
change plans and to proceed with autogenous reconstruction using bilateral free
TRAM aps.The nal reconstruction was accomplished in two stages; despite the
presence of a right lower paramedian incision, the perforators on the right side had
not been completely disrupted. (The second operation is depicted in Chapter 31.)

The degree of tissue expansion will vary, depending on the initial mode of expan-
sion and how much overin ation may have been done. Overin ation may be help-
ful in patients undergoing radiotherapy; however, in those who do not require ra-
diotherapy, I in ate only as much as necessary to accommodate the nal implant.
The most important consideration is the positioning of the recon-
structed inframammary fold at the proper level and the development
of a compliant soft tissue envelope that will be suspended from the in-
framammary fold.Textured-surface expander devices have been help-
ful in allowing the latter to occur.
When the previously placed expander or implant has produced a reasonably good
shape along the inframammary fold, the most important considerations are the di-
ameter of the base of the reconstructed breast and its projection. Shaped saline and
silicone gel devices are preferable in implant breast reconstruction, simply because
the available soft tissue coverage has no shape of its own.The key to implant selec-
tion is to choose the implant according to the optimal base diameter and projec-
tion, with the volume being less important than the dimensions. However, the
nal volume should be roughly similar to the volume of the opposite breast. An in-
dicator of the volume can be derived from the weight of the mastectomy specimen.
1323
Chapter 35
Reoperation Following Implant Breast Reconstruction
We had the opportunity to see this 26-year-old woman with an advanced right
breast cancer before her mastectomy.The challenge in this patient was to try to re-
store symmetry with a relatively youthful opposite breast. We did not feel that we
could achieve symmetry with an implant reconstruction alone.

1324
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The right latissimus dorsi musculocutaneous ap allowed an initial expansion of
the lower pole, in essence recreating the original defect. An expander was placed
and the postexpansion result is shown. Analysis of the ongoing asymmetries at this
point reveals a higher, fuller reconstructed breast and a grade II ptosis of the nor-
mal left side. Since we cannot create additional ptosis on the right, we recom-
mended a simple left reduction mammaplasty along with considerable reduction of
the latissimus skin island as well as nipple-areola reconstruction.
The nal reconstructive result is shown at 1 year as well as the back donor site.
The opposite breast will always serve as the template for symmetrical
reconstruction.