Reoperative Plastic Surgery of the Breast

42
Reoperative Plastic Surgery of the Breast
her previous IM incisions (Fig. 2-36C). The lateral
extent of the scar initially was found to lie off the
breast (Fig. 2-36D). The scar was redirected by excis-
ing a triangle of skin superior to it to create a curved
line of incision in a more favorable location on the
inferior lateral breast (Fig. 2-36E).
Scar Hypertrophy
As previously noted, scars are permanent marks that
never completely go away. They may heal as fine,
almost indistinct lines as in the IM fold region fol-
lowing most breast augmentation performed
through this incisional approach. However, they can
appear thick and hypertrophic. Hypertrophy is most
commonly seen in the lateral aspect of the lower
breast and is often noted following breast reduc-
tions done using the Wise pattern of skin incisions
(Fig. 2-37). If hypertrophy in a scar occurs, the appli-
cation of pressure applied by a bra with or without a
silicone sheet may soften the scar. Alternatively, a
small amount of a depot steroid can be injected into
the scar. I prefer to use Kenalog 40 and will inject a
maximum of 1 cc. It is important not to inject this
medicine into the subcutaneous tissue because it
may cause atrophy of the adipose tissue that often
may result in an indented appearance of the scar. In
addition, it is important for the surgeon to inform
FIGURE 2-36. (CONTINUED) C, The scar is seen to descend
below the IM fold. D, Redirection of the lateral limb of the IM
incision is accomplished by excising triangles to create unequal
incision lengths at the line of closure. E, The scar has been repo-
sitioned into the IM fold laterally.
FIGURE 2-37. Scar hypertrophy noted in the lateral and
medial aspect of the IM incision in a patient who had a breast
reduction with an inverted T incisional pattern.

the patient about the possibility of hypopigmenta-
tion or color change in the scar with such a steriod
injection. Colors that I have encountered following
steroid injections include a blue, purple, or violet
color that may be distinctly different from the color
of the scar tissue and surrounding skin. If a scar
revision is pursued, I find that it is best to wait at
least 1 year before performing such surgery to allow
the maximum chance for maturation and softening
of the scar.
Scars can extend from the skin surface to deep
within the breast parenchyma. It is possible to make
this diagnosis by palpation of the tissues. Most com-
monly all of the tissues in these wounds are
indurated with the skin being adherent to the under-
lying breast parenchyma, which can be quite firm. It
is imperative that the surgeon allows the return of
tissue equilibrium to the entire wound before con-
templating a reoperative surgical procedure. This
process usually requires at least 6 months, but often
it is necessary for 9 months or 1 year to elapse
before the induration completely resolves and a sub-
stantial degree of softness returns to the tissues.
Having the patient perform daily deep wound mas-
sage may help hasten the progress of the wound into
the latter phases of chronic wound healing and the
tissues to a condition of softness. Suffice it to say
that only after such tissue equilibrium has been
acquired within the wound can the most precise
manipulations for tissue movement and breast
reshaping be carried out.
Scars will occasionally cross the contour lines of
the breast. In such locations they will be highly visi-
ble because they alter the natural contours of the
breast silhouette. In this situation it may be possible
to change and redirect the scars by tissue rearrange-
ments, flap transfer, or Z-plasty technique. In gen-
eral I believe that it is best to avoid obvious
geometric scar formations (Z-plasties and W-plas-
ties) on the immediately visible portions of the
breast.
Skin scars can also be invaginated. This most
often occurs as a result of a discrepancy between the
heights of skin surfaces on either side of the wound
or following wound separation and healing by sec-
ondary intention. If this invaginated appearance is
exaggerated, it can be a definite problem for the
patient. In these situations, when there is an ade-
quate subcutaneous adipose tissue layer, it is often
possible to excise the original wound, elevate the
skin immediately below the dermis, and create flaps
of subcutaneous tissues at different levels. Wound
reapproximation then includes advancing these
flaps of subcutaneous tissue past each other, thus
stacking this layer beneath the skin incision and cre-
ating a vertical Z-plasty within the wound. A precise
reapproximation of the skin finishes the closure.
The return of tissue equilibrium, which occurs
approximately 1 year following the redo stacked
wound repair, often improves the invaginated
appearance of the skin scar.
As noted, the presence of a scar(s) can visually
detract from the aesthetic appearance of the breast.
In addition, scars can negatively affect the blood
supply of the breast skin, and this must be borne in
mind whenever skin flaps are raised on a breast with
a previous incision. This is especially common when
performing a breast reduction or mastopexy in the
setting of a previous breast surgical procedure.
Therefore in such settings the surgeon should alter
the design of incisions and pattern of skin flap devel-
opment to avoid raising flaps with scars at their base
as much as is possible. It is particularly important
for the surgeon to analyze the relationship of previ-
ous scars to the NAC. Any reoperative procedure on
the breast in this setting must be planned to main-
tain circulation to this critical structure. In every
previous breast operation in which the nipple has
been moved on a pedicle, such as a breast reduction
or mastopexy, I believe that it is critical for the sur-
geon to know exactly what pedicle design was used
so as to best maintain adequate nipple vascularity in
any subsequent procedure.
I believe that the incidence of skin necrosis is sig-
nificantly increased in every breast operation where
a previous breast incision has been placed. This is
especially true when raising random pattern breast
skin flaps with a large length-to-width ratio. An
example of this is illustrated in Figure 2-38 in a
patient who requires a mastectomy after the previ-
ous excision of two fibroadenomas performed
through a long incision on the superior aspect of the
left breast (Fig. 2-38A). This mastectomy was com-
plicated by ischemic necrosis of the skin at the mar-
gins of the mastectomy incision (Fig. 2-38B) that
required an additional surgical debridement (see
Fig. 8-5A–F).
When a mastectomy is to be performed in the
presence of a previous incision, it is most often
advisable to elevate skin flaps that are as short as
possible and not have a scar transgressing the base
of the skin flap. In some instances it is not possible
to accomplish this, and in such settings there is an
increased chance for wound healing difficulties. In
these situations the surgeon must be very analytic in
assessing the vascularity of the remaining skin flaps.
I often use intravenous fluorescein injection and
examination with a Wood’s lamp to increase the
accuracy in assessing the state of skin blood flow in
this setting (Chapter 8).
Chapter 2
Breast Aesthetics in the Nonoperated and Reoperative Breast
43

44
Reoperative Plastic Surgery of the Breast
Contour Abnormalities
Abnormalities in contour are often noted following
previous breast surgery. Perhaps the most common
are elevations of skin at the ends of the incisions
often called dog ears. They are the result of a well-
intentioned effort to minimize the length of an inci-
sion and are most often noted following breast
reduction and mastopexy. They are also commonly
seen in the setting of breast reconstruction. In gen-
eral it is best to excise such dog ears at the initial
procedure—especially if they are medially located.
The excision should be accomplished to allow the
scar to lie in the breast contour or within the
shadow of the breast contour. Secondary excision
results in a longer scar, and this must be explained
to the patient preoperatively.
Dog ears are most often addressed by combined
skin and subcutaneous adipose tissue excision. In
some cases of small dog ears, the excision of subcu-
taneous adipose tissue alone will allow the skin to lie
flat on the breast contour. I find that it is almost
always necessary to excise a significant amount of
adipose tissue to effectively treat a large dog ear.
Deficits of subcutaneous adipose tissue are also not
uncommon after all types of breast procedures. They
most often are noted at the periphery of the breast.
Such abnormalities produce indentations or depres-
sions in the surface contour of the breast, and they
can be very noticeable and bothersome to the patient.
Classically the treatment has involved filling in
such indentations or deficits of contour with either
adipose tissue flaps or dermis fat grafts. A technique
that I find helpful when there is excess skin and adi-
pose tissue adjacent to the contour deficit is the
advancement of a de-epithelialized flap of adipose
tissue. It is the leading edge of a skin flap that is
advanced, and when sutured the adipose flap is held
in the appropriate position. This technique is
diagrammatically illustrated in Figure 2-39 and is
extremely helpful for both lateral and medial areas
of the breast when both the skin and the sub-
cutaneous adipose layer contours require revision.
A de-epithelialized leading edge of a random pattern
skin flap can be a very helpful tool for reconstruct-
ing a contour deficit with an indentation of tissue
that is adjacent to an area of contour prominence. It
is most often used for reconstruction of indenta-
tions in the superior medial breast area or along the
lateral contour of the breast (see Fig. 8-22C).
Dermis fat grafts are also helpful to treat small
contour deficits. Their utility is limited by size, i.e.,
only small amounts (thickness) of adipose tissue can
be included with such grafts. The important aspects
of technique are precise pocket dissection at the site
of the defect, meticulous hemostasis, and orienting
the graft such that the de-epithelialized dermal side
of the graft is placed superiorly against the dermis.
The patient should be informed about the need for a
donor site scar and that there is often a long period
of induration at the site of graft placement before
eventual graft softening. With these limitations in
mind, successful results can be achieved when
small, nonradiated defects are reconstructed using
dermis fat grafts.
Currently autologous fat grafting done with the
injection of freshly harvested adipose cells is gain-
FIGURE 2-38. The impact of skin scars on the healing of subse-
quently elevated breast skin flaps. A, AP view of a patient who has
undergone a previous fibroadenoma excision in the upper pole of
the left breast and who now requires a total mastectomy for dif-
fuse ductal carcinoma in situ of the breast. B, Appearance of the
breast 6 days after mastectomy and immediate breast reconstruc-
tion with a TRAM flap. Note the ischemic change at the margins
of the incision, which required operative excision. The previous
upper breast incision most likely produced a decrease in skin cir-
culation that resulted in marginal skin flap necrosis.

Chapter 2
Breast Aesthetics in the Nonoperated and Reoperative Breast
45
FIGURE 2-39. A–D, Diagrammatic illustration of contour deficit correction using a de-epithelialized
lead edge of an adjacent random pattern skin flap.
scar
skin
A
B
C
D
Dermis fat
flap
advanced
Contour
deficit
reconstructed
Release scar
tissue to
"recreate
defect"
de-epitheliaze
ing popularity for treating contour abnormalities of
the breast. I have had much experience treating
small peripherally located contour abnormalities in
the breast and can attest to its efficacy. Such grafts
may be harvested from a variety of donor sites
using a 1-mm liposuction cannula (Fig. 2-40A) after
the infiltration of the area with an epinephrine-con-
taining solution. Alternatively, a blunt-tipped 14-
gauge needle may be used for very small amounts of
fat harvest (Fig. 2-40B). The harvested fat tissue
must then be separated from the fatty oils. This is
done either by gravitational settling or by centrifu-
gation (Fig. 2-41A). The supranatant fat tissue layer
is then transferred to 1-cc syringes and is injected
into the defect through 14-gauge needles (Fig. 2-
41B). The fat is injected into the tissues at the site of
the defect in strands. It can be injected into the
subcutaneous adipose tissue, muscle tissue, and a
previously transferred flap. It is important not to
clump the fat. I perform only minimal overcorrec-
tion of the defect.
It is not uncommon to note some resorption of the
autologous fat grafts. Such grafts can be redone,
usually 4 to 6 months following the previous fat
graft. Microcalcifications can accompany graft
resorption, but its appearance is usually easily differ-
entiated from the microcalcifications that may be
associated with malignancy. I have found that previ-
ous radiation to the breasts significantly compro-
mises the success of this technique. With these
limitations in mind, autologous fat grafting is a tech-
nique with an ever-expanding role for treating con-
tour abnormalities in all areas of the body, including
the breast. Examples of these methods for correcting
contour deficits are illustrated later in this chapter
and in subsequent chapters throughout this book.

46
Reoperative Plastic Surgery of the Breast
Previous Breast Implant Surgery
The previous placement of a breast implant always
produces predictable changes in the local tissues.
Most commonly seen are stretching of the skin and
PMM, along with compaction of the overlying sub-
cutaneous adipose tissue and muscle layer (if the
implant was placed in a submuscular position). The
net result almost always is some element of tissue
stretching, and in some cases frank tissue attenua-
tion and decreased tissue elasticity.
Periprosthetic Capsular Surgery
A periprosthetic collagen envelope or scar tissue
capsule of varying thickness forms around every
implant that has been placed. Reoperative surgery
following a breast augmentation or previous
implant-based breast reconstruction is performed to
treat problems of asymmetries relating to implant
malposition, abnormal IM fold position, or contrac-
ture of the periprosthetic capsule. For virtually all of
these problems, alteration of the capsule by direct
FIGURE 2-41. A, Appearance of harvested fat after centrifugation at 3,000 rpm for 5 minutes. B, Fat
graft material is then transferred to 1-cc syringes for injection.
FIGURE 2-40. Harvesting autologous fat grafts by aspiration with a 1-mm cannula (A) and a
14-gauge blunt-tipped needle (B).

Chapter 2
Breast Aesthetics in the Nonoperated and Reoperative Breast
47
incisional release, suture capsulorrhaphy, or cap-
sulectomy represents the most common approach.
Suture capsulorrhaphy (see Fig. 3-36), strip cap-
sulectomy (Chapter 6), and capsular flap applica-
tion (Chapter 3) are particularly powerful tools in
achieving alteration on the periprosthetic capsular
space and for substantially modifying the appear-
ance of a breast with a previously placed implant.
Suffice it to say that in many instances of reoper-
ative surgery following previous implant placement
the periprosthetic capsule, in a paradoxical way, is
an asset for the surgeon reoperating after previous
breast implant surgery. The ability to precisely alter
this capsule has a powerful effect on implant posi-
tion and therefore on both the shape and contour of
the implanted breast. Becoming proficient with
these techniques pays significant dividends for the
surgeon performing reoperative surgery in this set-
ting from the standpoint of achieving satisfactory
outcomes in many of these cases.
Often, reoperative surgery in a patient with a pre-
vious breast implant involves a decision about
whether to perform a capsulectomy. In many clinical
situations this is a prudent or even necessary course
of action. This is especially true when addressing the
problem of rupture of a previously placed silicone
gel implant or when the surgeon must deal with a
severe, recalcitrant capsular contracture when the
plan entails placement of a new implant. In such sit-
uations, performing a total or subtotal periprosthetic
capsulectomy removes as much of the silicone gel as
possible and produces a virginal pocket into which a
new implant can be introduced. I believe this is espe-
cially important when a change of the implant sur-
face (most often substituting a textured surface
device for a smooth surface implant) is done in
hopes of decreasing the chance for development of a
recurrent capsular contracture.
Caution must be exercised in performing a cap-
sulectomy in patients with very thin or significantly
attenuated overlying tissues. The most prominent
examples of such situations are patients who have
undergone subglandular breast augmentation with
large implants and those who have undergone implant
reconstruction of the breasts following a previous sub-
cutaneous mastectomy. A total capsulectomy in these
settings may compromise the circulation to the overly-
ing skin, which can threaten a subsequent implant.
Often it is safer to leave portions of the capsule either
on the anterior or posterior surface, opting for a subto-
tal periprosthetic capsulectomy.
Issues involved in preoperative decision making
with regard to the management of the periprosthetic
capsule and technical details about its performance
are extensively reviewed in Chapter 4.
THE EFFECT OF IMPLANT PLACEMENT
ON BREAST PARENCHYMAL
VASCULARITY AND NIPPLE AREOLAR
BLOOD SUPPLY
It must be borne in mind that placing an implant in
the subglandular position definitely decreases the
blood supply of the breast tissue and overlying skin,
including the NAC (Fig. 2-42). Dissection to develop
FIGURE 2-42. Reduction in blood supply to the NAC following subglandular placement of a breast
implant for breast augmentation.

48
Reoperative Plastic Surgery of the Breast
this plane interrupts a substantial amount of the
blood supply from the PMM (musculocutaneous
perforators from the thoracoacromial vascular pedi-
cle), and to a lesser extent it may decrease contribu-
tions from the internal mammary and lateral
thoracic vessels. This is especially important for the
surgeon to realize when he or she is contemplating a
combined redo breast augmentation and a concomi-
tant mastopexy in the setting of a previous subglan-
dular breast augmentation. Such combined surgery
may entail a significant risk for wound breakdown
along the skin incision. More important, there is a
decrease in NAC blood supply, which may be signifi-
cant in the setting of such combined surgery when a
significant transposition of the NAC on a parenchy-
mal pedicle can have dire consequences in terms of
NAC viability. In this setting it is often advisable to
stage the procedures of redo augmentation and
mastopexy. This caution most strongly applies to
patients who use nicotine products.
AESTHETIC PRIORITIES IN REVISIONAL
BREAST SURGERY
Priorities in revision surgery are often patient
driven. Patients often come in to the office with a
specific complaint or requesting specific changes
in breast appearance. These complaints are
related to many issues we have discussed and are
listed in decreasing order according to frequency
in Table 2-1.
The classic tradeoff that most plastic surgeons
have been taught is that of “scars for shape.” Most
patients will accept additional scars on their breasts
for improved shape. The plastic surgeon must bear
in mind that scars on the breasts can detract from
breast appearance. In general, patients should be
informed about the exact or potential location of
such scars preoperatively. As outlined earlier (see
Fig. 2-30A), incisions made in certain locations on
the breast tend to heal with more aesthetically
acceptable scars than incisions in other locations.
Incisions at the junction of the areola and breast skin
are most favorable. Such incisions should be placed
exactly in the junction between the areola and breast
skin because they tend to undergo hypopigmenta-
tion and thus will be most concealed if placed in the
breast skin–areola junction. Alternatively, scars
placed in the IM fold or in the natural curve of the
breast in general also heal well. As illustrated in
Figure 2-36A–E, at times it may be possible to redi-
rect a scar or move it to a slightly different location
on the breast so it will be less obvious.
Scars in the IM region also heal well and are con-
cealed with the patient in the upright position. Scars
from incisions made on the breast proper tend to
heal best if they are curvilinear in shape and are par-
allel with the margin of the areola (see Fig. 2-30A).
Any scar can undergo hypertrophy and appear
thick and offensive. Breast incisions placed medially
in the parasternal area most often tend to do this
(Fig. 2-43A). Often incisions placed laterally in the IM
fold will also hypertrophy. Patients are often both-
ered by and request treatment for a scar that exhibits
a hypertrophic appearance. Most often in this situa-
tion, the best medicine for the patient and the sur-
geon is the tincture of time; time must be allowed to
elapse so that such scars may have a chance to
mature. Many scars will soften and fade in color. In
some cases the hypertrophic appearance will persist.
At times these hypertrophic scars can also be painful.
This makes them doubly bothersome to the patient.
Scar hypertrophy can be addressed by taping the
scars (I have found that placing paper tape on fresh
scars seems to limit the tendency of hypertrophy),
massaging the scars, injecting depot steroids into the
scar itself, or applying silicone gel sheeting. My per-
sonal experience with the latter approach has been
somewhat disappointing.
Scars can invaginate. Such a problem is most
often related to underlying tissue deficiency and/or to
dense subcutaneous cicatrix, producing an adhesion
to the deeper tissues. In cases that are not responsive
to aggressive massage, release of the cicatrix done
through a small incision with the placement of
injected autologous fat or a dermis fat graft is often
helpful as illustrated by the following patient.
This 55-year-old diabetic patient had previously
undergone a right mastectomy and implant-based
reconstruction for stage II breast cancer when she
developed breast cancer in her left breast. This oppo-
site breast was treated by lumpectomy and radiation
therapy. The patient developed an invagination of her
lateral breast incision, as well as a depression at the
site of a previously placed intravenous access catheter
in the parasternal area of the upper medial aspect of
her left breast (Fig. 2-44). The subcutaneous cicatrix at
both sites was released and she had the injection of
◗TABLE 2-1 Reasons for Revisional Breast Surgery
●Contour problems: change in shape
●Volume: excess or deficiency
●Nipple areolar asymmetry: position, size, inclination
●Problems with base dimension: base width and height
●IM fold abnormalities: asymmetry, constriction, "double bubble"
●Skin envelope problems: amount, color
●Scar deformities
IM, inframammary.

Chapter 2
Breast Aesthetics in the Nonoperated and Reoperative Breast
49
30 cc of autologous fat in conjunction with a dermis
fat graft below the lateral breast incision and a dermis
fat graft placement to reconstruct the contour deficit
in the superior medial aspect of her breast (Fig. 2-45).
At 2 years she demonstrated a marked improvement in
the contours of both areas (Fig. 2-46A,B). She is one of
many patients with small contour defects following
previous surgery that I have treated in this way.
FIGURE 2-44. Appearance of scar hypertrophy and contour
abnormality in a 55-year-old patient who had a lumpectomy and
radiation therapy for a stage II cancer of the left breast. Note the
invagination of the horizontal scar on the lateral aspect of her
breast from where the tumor had been excised.
FIGURE 2-45. Planned correction of contour deficits. Dermis
fat grafts were used at both sites with the addition of autologous
fat injection under the lateral breast incision.
FIGURE 2-43. A, Severe contour abnormality of right breast
noted following lumpectomy and radiation therapy for right
breast cancer. Also note the hypertrophic scar in the parasternal
aspect of the left breast. B, Note contour deformity. Also note
hypertrophic scar parasternal aspect of left breast with contour
depression following placement of chemotherapy port.

Contour—Problems with Dimension
and Shape
Contour may be the most important characteristic
defining breast appearance. It is made up of the pro-
jection, recesses, highlights, shadows, and lines that
produce the visual gestalt of the breast. The eye will
immediately pick up abnormal contour. In my expe-
rience the most common reason for revising a previ-
ous breast surgical procedure is to address problems
with shape or contour and their effect on symmetry.
These abnormalities can be subtle, such as the
difference in the superior medial fullness of the
breasts seen following bilateral breast reconstruc-
tion with transverse rectus abdominis muscle
(TRAM) flaps (Fig. 2-47), or not so subtle deformi-
ties as illustrated in an abnormal contour of the
lower breast following lumpectomy and radiation
therapy (Fig. 2-48). The eye notes both deviations
from what it expects to see, and these abnormal con-
tours represent a very common reason for reopera-
tive breast surgery.
Adequate dimensional restoration of the breast
silhouette, especially in terms of base width, is an
important concept from the perspective of creating
symmetry of contour. This is illustrated by this
patient, who was treated for a left postmastectomy
defect with an immediate insertion of a tissue
expander (Fig. 2-49A). She elected to have a con-
tralateral breast augmentation. Her reconstruction
revealed both medial malposition of the implant
that also had an inadequate base width that resulted
in a lateral rib show (Fig. 2-49B). This was treated
by correction of the medial malposition using a dou-
ble capsular flap technique (Fig. 2-49C; see Chapters
3 and 6) and replacement of her implant with a
larger base-width device (Fig. 2-49D). The ultimate
restoration of breast symmetry requires precisely
accurate positioning of the NACs (Fig. 2-49E). The
result following nipple reconstruction (Fig. 2-49F)
and intradermal tattoo revealed an excellent aesthetic
appearance of the breasts.
This case illustrates several important concepts of
aesthetic analysis and surgical correction of abnormal
breast aesthetics. Restoring the appropriate silhouette
of the breast from the standpoint of breast dimension
and the correct position of the breast mound on the
chest wall, along with the re-establishing the right
shape and contour, was the first step. The finishing
touches of both nipple reconstruction and the addi-
tion of the areolar pigmentation by the intradermal
tattoo have transformed the more symmetric breast
mounds into aesthetically pleasing breasts.
50
Reoperative Plastic Surgery of the Breast
FIGURE 2-46. Appearance of contour deformities corrected by dermis fat graft for parasternal inden-
tation and cicatrix release and autologous fat injection beneath horizontal scar seen at 2 years postop-
erative. A, AP view. B, Lateral view.

FIGURE 2-47. Somewhat subtle asymmetry of superior medial
breast fullness seen in this patient who underwent bilateral
breast reconstruction with TRAM flaps.
FIGURE 2-48. Significant breast asymmetry with marked con-
tour deformity in patient who underwent a previous lumpec-
tomy with resection of tissue in the lower pole of the breast
centrally with subsequent radiation therapy.
FIGURE 2-49. This sequence illustrates the impact of revision surgery on breast aesthetics. A, This
41-year-old patient requires a left mastectomy and she elects to undergo a staged reconstruction of the
breast with a tissue expander followed by an implant with a plan for a contralateral breast augmenta-
tion with silicone gel implants. Note the medial malposition of the tissue expander. B, The second stage
produced a suboptimal breast reconstruction with medial malposition of the implant, which had too
narrow a base width for the patient’s chest dimension. (continued)

52
Reoperative Plastic Surgery of the Breast
FIGURE 2-49. (CONTINUED) C, This required a revision to correct the medial malposition using a
double capsular flap technique; breast implant with greater base width and volume was chosen. D, This
improved the breast silhouette and shape. E, The plan for nipple reconstruction illustrates the symme-
try achieved by this reoperative procedure. F, The intradermal tattoo completes the aesthetic revision,
transforming the breast mound into a lifelike breast facsimile.

Chapter 2
Breast Aesthetics in the Nonoperated and Reoperative Breast
53
Spreading of Scars Secondary to Skin
Loss
Skin abnormalities include scar deformities and
qualitative deficits, as well as other qualitative
abnormalities. A common denominator for many
of these problems is skin loss at the margin of a
skin flap that may have been closed with excess
tension. This results in an open wound that most
often heals by contraction and epithelialization,
often with a suboptimal cosmetic appearance of
the eventual scar.
Skin loss is not at all uncommon following breast
reduction (see Chapter 6), and the resulting lighter,
wider, somewhat depressed scars can detract from
the overall appearance of an otherwise pleasing
breast reduction as illustrated by this patient (Fig.
2-50A), whose vertical scar breast reduction caused
significant skin loss in its lower aspect, resulting in a
wide, unattractive scar (Fig. 2-50B). The patient did
not pursue scar revision. In this case healing by con-
traction and epithelialization did not detract from the
shape or appearance of the breasts (Fig. 2-50C,D).
However, when such skin loss results in a more
FIGURE 2-50. A, Preoperative AP view of a patient who will undergo a vertical breast reduction.
B, Significant skin loss in the lower aspect of the vertical incision resulted from excessive tension on the
skin and a superimposed Staph infection, which prolonged the time to complete healing. C, Topical and
orally administered antibiotics produced tertiary wound healing. D, The widened scar is hidden on the
undersurface of the breast; it does not detract from the shape or appearance in the upright position and
the patient did not wish to pursue scar revision.

54
Reoperative Plastic Surgery of the Breast
FIGURE 2-51. A, Skin loss noted on the medial aspect of the lateral skin flap immediately following an
inferior pedicle breast reduction using a Wise pattern. B, Following epithelialization and contraction there
is an unstable scar and prolapse of the breast tissue through the wound producing an abnormal lower pole
breast shape. C, Revision is undertaken to excise the scar tissue and to close the resulting wound in layers.
D, Two-year follow-up demonstrates better scars and better contour of lower pole of both breasts.
noticeable scar deformity or produces a contour
deficit such as in this patient (Fig. 2-51B), who had
prolapse of her breast tissue and an abnormal breast
shape of the lower pole following a breast reduction
that was complicated by skin loss of the medial aspect
of the lateral flap in the immediate postoperative
period (Fig. 2-51A). Revision of the scar (Fig. 2-51C)
with excision and multiple layer closure produces a
better appearance of the skin and a better contour in
the breast. Here scar resection, re-elevation, and
advancement of skin flaps produced an improvement
in contour and scar appearance (Fig. 2-51D).

FIGURE 2-52. A, The plan for an immediate right breast reconstruction with a unipedicle TRAM flap
following previous lumpectomy. B, The initial postoperative result shows a breast asymmetry with
excess volume in the reconstructed right breast and an aesthetically undesirable patch effect from the
skin paddle inset. C, The plan is for volume reduction of the TRAM with suction lipectomy. D, The post-
operative result is shown 2 years later.
Volume
Volume asymmetries are very common. These can
relate to excess volume or volume deficiencies.
Volume excess is encountered in a variety of reopera-
tive settings in the prospective breast surgery patient.
Most commonly this is seen in the breast reconstruc-
tion patient population and most specifically after
TRAM flap breast reconstruction, where it is com-
mon to overbuild the breast. This patient (Fig. 2-52A)
underwent a combined delayed left breast recon-
struction with a TRAM flap and a contralateral right
breast reduction. Postoperatively she was seen to
have a volume asymmetry between the breasts
(Fig. 2-52B). This was treated by liposuction and a
minimal reduction of the TRAM flap skin paddle by

56
Reoperative Plastic Surgery of the Breast
FIGURE 2-53. A, This is a 70-year-old patient who will
undergo a bilateral breast reduction for symptomatic macro-
mastia. B, The procedure resulted in a volume asymmetry with
the right breast substantially larger than the left. C, The plan is
to address this asymmetry with liposuction alone to reduce the
volume of the right breast. The estimated volume excess is
between 70 and 100 g of tissue.
direct excision. Comitant nipple areola reconstruc-
tion produced volume symmetry and created a nice
finishing touch for the reconstruction (Fig. 2-52C).
Volume asymmetry can also be seen after breast
augmentation or breast reduction. This 70-year-old
patient presented to my office with symptomatic
macromastia (Fig. 2-53A) and underwent a breast
reduction. She had a resection of 680 g on the right
and 640 g of tissue on the left that resulted in a visi-
ble volume asymmetry (Fig. 2-53B). She is sched-
uled for a revision of this procedure during which
liposuction of the right breast will be used to
address the excess fullness of the right breast.
Liposuction is a very effective way of reducing the
adipose volume in the breast (Fig. 2-53C). It is find-
ing increasing application in primary breast reduc-
tion procedures in patients with fat replacement of
their breast tissue.

Chapter 2
Breast Aesthetics in the Nonoperated and Reoperative Breast
57
FIGURE 2-54. A, AP view of a patient who underwent a left
modified radical mastectomy with an ultimate skin-sparing
approach. She underwent immediate TRAM flap reconstruction.
B, A modified star flap was used for nipple reconstruction and
appears to detract from the breast aesthetics. C, An intradermal
tattoo restores excellent breast aesthetics.
Nipple Areolar Complex
The NAC is the visual focal point of the breast. All
visual lines converge toward it, and the eye is imme-
diately drawn to it. It has a powerful impact on
breast aesthetics. This is illustrated by the following
two patients. The first is a young woman who
underwent an elective breast reduction using a clas-
sic “inverted T” incisional pattern. The outcome of
this 1800-g reduction is quite superior from an aes-
thetic standpoint. This is due to the symmetry of
shape. Of note are the positions and dimensions of
the NACs, which are appropriately positioned and
very symmetric in size (see Fig. 2-32).
A similar situation is seen in this breast recon-
struction patient who underwent an immediate

58
Reoperative Plastic Surgery of the Breast
breast reconstruction with a TRAM flap following
an ultimate skin-sparing mastectomy (Fig. 2-54A).
The subsequent nipple reconstruction appeared to
decrease the visual aesthetics (Fig. 2-54B). This was
rescued by an intradermal tattoo that produced
color patch symmetry and a true dimension of real-
ism (Fig. 2-54C).
Asymmetries or discrepancies of nipple areolar
position, projection, and pigmentation, as well as
overall size and shape, detract from the overall
visual appearance and therefore from breast aes-
thetics. This is illustrated by the following patients.
The first patient underwent a breast reduction for
mild macromastia and ptosis (Fig. 2-55). She imme-
diately noted a discrepancy in areolar size postoper-
atively that was very bothersome to her and
required a revision. The details of this revision are
outlined in Chapter 5. This was addressed by down-
sizing the areolar diameter and controlling the sur-
rounding skin with a purse string suture. This
produced better symmetry between the NACs. This
illustrates the concept of taking time to ensure the
best possible symmetry between the NAC from the
standpoint of size, shape, and position.
FIGURE 2-55. A, This 36-year-old female is shown 6 months
after a bilateral breast reduction. There is an obvious asymmetry
of the NACs in terms of size, shape, and position, which bothers
the patient. B, The plan is to decrease the size and elevate the
position of the NAC on the breast. C, An early postoperative AP
view illustrates correction of the nipple asymmetry.

Chapter 2
Breast Aesthetics in the Nonoperated and Reoperative Breast
59
COMBINED DEFORMITIES—
DISCREPANCIES OF VOLUME AND
NIPPLE POSITION
Most reoperations on the breast that I perform are
done to address derangements in more than one of
the areas listed previously. That is to say, contour
deformities are usually accompanied by scar prob-
lems, volume asymmetries, or NAC discrepancies.
A common example in my practice is the
postlumpectomy patient whose asymmetry relates
to volume, shape, contour, nipple areolar displace-
ment or dislocation, and a scar abnormality. These
findings are superimposed on the setting of previous
radiation therapy.
The following patients illustrate a deviation from
ideal breast aesthetics after lumpectomy and previ-
ous radiation. This first patient (Fig. 2-56A) had a
lumpectomy to treat a left breast cancer performed
through a lateral areolar incision. She presented
with an asymmetry relating to greater breast vol-
ume, larger base dimension, and lower nipple areo-
lar position on the right side. These issues were
addressed by performing a right vertical mastopexy
(Fig. 2-56B) with resection of 150 g of breast tissue.
This significantly enhanced the symmetry between
her breasts. However, the patient had a lateral incli-
nation of her left NAC (Fig. 2-56C) that produced a
visible asymmetry in the AP position and slightly
marred what otherwise was a very good result.
FIGURE 2-56. A, This is a 55-year-old patient who underwent
a left lumpectomy and radiation therapy for breast cancer. She
presented for correction of the resulting breast asymmetry
marked by a difference in volume, nipple position, nipple areolar
inclination, and degree of ptosis. B, The plan was to perform a
right vertical mastopexy. C, At a 1-year follow-up the patient
demonstrates markedly improved breast aesthetics despite the
persistent nipple areolar asymmetry.

60
Reoperative Plastic Surgery of the Breast
Discrepancies of Contour, Volume, and
Nipple Position
This next patient presented with a marked contour
deformity, volume asymmetry, and nipple disloca-
tion after a lumpectomy in which a large segment of
tissue was removed from the central portion of the
lower pole of her left breast (Fig. 2-57A,B). These
deformities are principally related to excessive
parenchymal resection, which is related to the rela-
tively small breast volume (see Chapter 9). She was
managed by reconstruction of her volume deficit
following scar tissue resection using a TRAM flap
(Fig. 2-57C,D). There was virtually no skin replace-
ment needed. The overall outcome indicated
restoration of normal breast aesthetics.
FIGURE 2-57. A, Preoperative AP view of patient with severe combined deformity of right breast
marked by a contour abnormality, nipple dislocation, and volume discrepancy. This occurred following
lumpectomy and radiation therapy for tumor in the central inferior aspect of the breast. B, Oblique
view. C, AP view following correction of these aesthetic problems with a TRAM flap reconstruction of
the postlumpectomy defect. D, Oblique view following revision of the previous lumpectomy defect.

Chapter 2
Breast Aesthetics in the Nonoperated and Reoperative Breast
61
COMBINED DEFORMITIES—
INADEQUATE VOLUME, PROJECTION,
AND CONTOUR
This 36-year-old female presented with a breast asym-
metry following a postmastectomy right breast recon-
struction. This was performed for recurrent breast
cancer after lumpectomy and radiation therapy. The
implant-based breast reconstruction showed an
abnormal shape due to capsular contracture, inade-
quate volume, and local tissue atrophy (Fig. 2-58A).
The previous reconstruction was selected because of
inadequate autologous options. The right breast revi-
sion was done in stages with skin deficit replacement
and soft tissue reconstruction with a TRAM flap
(Fig. 2-58B) and then subsequent implant placement
beneath the flap (Fig. 2-58C). This produced much
improved symmetry as detailed in Chapter 8.
FIGURE 2-58. A, Breast asymmetry following staged implant-
based reconstruction of previously radiated breast. Note smaller
contracted breast implant. B, First stage reconstruction of
breast with replacement of skin and subcutaneous tissue using a
TRAM flap. C, Second stage involved placement of an implant
beneath the TRAM, which provided excellent symmetry with the
opposite breast.

62
Reoperative Plastic Surgery of the Breast
Inadequate Contour, Shape, Position,
and Volume
This 52-year-old female presented with a marked
breast asymmetry due to a severely contracted
saline implant reconstruction of the right
breast. This breast reconstruction was superi-
orly malpositioned with inadequate volume and
lower pole shape to match the opposite side (Fig. 2-
59A). In addition, there was a step-off deformity
superiorly, and the implant contained obvious
folds.
The plan was for autogenous conversion to a
TRAM flap. Tissue requirements dictated the use of
a free TRAM (Fig. 2-59B; see Chapter 7). The proce-
dure addressed the breast malposition, restored ade-
quate volume and shape, and replaced a small skin
deficit (Fig. 2-59C). The nipple areolar reconstruc-
tion produced good symmetry with the opposite
breast (Fig. 2-59D).
FIGURE 2-59. A, Malpositioned, severely contracted, saline implant right breast reconstruction. The
implant was placed beneath previously irradiated tissues. B, The plan included removal of the implant
and reconstruction of the breast with a free TRAM flap. (continued)

Chapter 2
Breast Aesthetics in the Nonoperated and Reoperative Breast
63
REFERENCES
1. Bostwick J III. Plastic and Reconstructive Surgery of the
Breast. 2nd ed. St. Louis: Quality Medical Publishers; 2000.
2. Penn J. Breast reduction. Br J Plast Surg. 1954;7:357.
3. Cooper, AP. On Anatomy of the Breast. London: Longmans;
1845:10.
4. Muntan CD, Sundine MJ, Rink RD, et al. Inframammary
fold: a histologic reappraisal. Plast Reconstr Surg. February
2000;105(2):549–556; discussion 557.
5. Boutros S, Kattash M, Wienfeld A, et al. The intradermal
anatomy of the inframammary fold. Plast Reconstr Surg.
September 1998;102(4):1030–1033.
6. Bayati S, Seckel BR. Inframammary crease ligament. Plast
Reconstr Surg. March 1995;95(3):501–508.
7. Grolleau JL, Lanfrey E, Lavigne B, et al. Breast base anom-
alies: treatment strategy for tuberous breasts, minor deformi-
ties, and asymmetry. Plast Reconstr Surg. December
1999;104(7):2040–2048.
8. Tebbetts JB. Dual plane breast augmentation: optimizing
implant-soft-tissue relationships in a wide range of breast
types. Plast Reconstr Surg. April 15, 2001;107(5):1255–1272.
9. Rees TD, Aston SJ. The tuberous breast. Clin Plast Surg. April
1976;3(2):339–347.
10. Millard PRS 1984, Maxwell 1980, Shestak Clinics.
11. Lejour M. Vertical mammaplasty: update and appraisal of
late results. Plast Reconstr Surg. September 1999;104(3):
771–781; discussion 782–784.
12. Hall-Findlay
EJ.
A
simplified
vertical
reduction
mammaplasty: shortening the learning curve. Plast Reconstr
Surg. September 1999;104(3):748–759; discussion 760–763.
13. Lassus C. A 30-year experience with vertical mammaplasty.
Plast Reconstr Surg. February 1996;97(2):373–380.
FIGURE 2-59. (CONTINUED) C, This produced an excellent revision of the breast reconstruction. D,
The nipple reconstruction provided an excellent finishing touch.

64
C h a p t e r 3
◗Revising the Unsatisfactory Breast
Augmentation
The Scope of Reoperative Surgery Following
Breast Augmentation 66
An Approach to Primary Breast Augmentation—
Patient Evaluation and Decision Making 66
Choosing an Implant 67
Implant Position 70
Selection of Incision 74
Infra-areolar Incision 74
Axillary Incision 75
Surgical Planning and Technique 76
Pocket Dissection 78
Subglandular Pocket Dissection 78
Subpectoral Pocket Dissection 78
Postoperative Management 81
Follow-Up Care 82
Revision of Breast Augmentation—History and
Physical Examination 82
Complications of Breast Augmentation 84
Acute Complications 85
Hematoma Formation 85
Seroma 89
Infection 89
Wound Dehiscence 92
Mondor’s Disease 93
Superficial Thrombophlebitis of the Axillary
Veins 94
Problems Related to Inadequate Preoperative
Planning and Surgical Technique 94
Implant Too Small—Patient Desires Larger Size
94
Minimizing Reoperations for Size Change 96
Reducing Breast Size Following Breast
Augmentation 96
Breast Asymmetries 99
Asymmetry of Breast Volume 100
Multifactorial Breast Asymmetry—Breast
Volume, Orientation, and Nipple Areola Position
and Inclination 100
Pre-Existing Breast Asymmetry due to Combined
Breast Volume and Rotational Deformity of the
Chest Wall 101
Inframammary Fold Asymmetries 101
Implant Malposition 107
Implant Too High 110
Implant Too Low 115
Inadequate Upper Pole Fullness due to
Insufficient Implant Size and Inferior
Malposition 115
Implant Too Low—Frank Inferior Malposition
115
Marked Inferior Implant Malposition 120

Chapter 3
Revising the Unsatisfactory Breast Augmentation
65
Breast augmentation is a very popular procedure with a
high degree of patient satisfaction.1 Over the past 4
decades many types of implants have been used to
increase the fullness of the female breast, with the major-
ity of these procedures involving the placement of a sili-
cone gel implant.2 Concerns about safety issues regarding
the silicone gel breast implant led the U.S. Food and Drug
Administration (FDA) to impose restrictions of their use
for routine breast augmentation in the United States in
1992.3 This prompted an immediate shift to saline-filled
implants for breast augmentation in the United States.
Subsequent scientific evaluations4–7 of the published liter-
ature on the silicone gel breast implant exonerated this
implant from any connection with disease production in
humans.
The most common inherent risk or unwanted side
effect of all implants is that of capsular contracture,2,4–9
which is an exaggerated form of the foreign body
reaction10 whenever a foreign substance is implanted in,
gains access to, or is accidentally introduced into the
human body. It is important to realize that this is an inher-
ent risk (not a complication) of every breast implantation
procedure (both breast augmentation and breast recon-
struction). The next most common inherent risk for
patients who have undergone breast augmentation is the
need to undergo additional surgery to treat a problem
with an implant.7
Revisional surgery following breast augmentation
occurs for a variety of reasons. These reasons relate to
technical aspects of the previous surgery, the implant
itself, or the response of the body to the implant. In addi-
tion, some breast augmentation patients request revision
for cosmetic issues such as inadequate size (change to a
larger implant); breast asymmetry; implant malposition;
implant palpability; and wrinkles, ripples, or folds seen in
the breast tissue and the skin overlying the implant. The
complications following breast augmentation are almost
exclusively local, i.e., they are confined to the breast
itself.7
Revision surgery following the previous placement of a
breast implant can be very challenging. This is due to the
effects of the previous surgery or the implant itself in the
form of tissue atrophy, scars in the skin and periprosthetic
capsular region, and decreased blood supply to the breast
parenchyma and nipple areolar complex (NAC), especially
when the implant was placed in the subglandular space.
For these reasons I believe that reoperative surgery fol-
lowing a previous breast augmentation carries a higher
risk of complications and patient disappointment than
does the primary augmentation procedure.
Because of this the plastic surgeon reoperating on a
patient following a previous breast augmentation must
spend the time necessary to communicate with the patient
regarding the goals, risks, and possible complications of the
surgery (Chapter 1, Appendix A). As outlined in Chapter 1,
I find it helpful to review the potential benefits and limita-
tions of the likely problems with the procedure with both
the patient and a significant other—either a friend, relative,
spouse, or significant other. This additional person is more
likely to hear the scope of potential adverse outcomes fol-
lowing such surgery and be able to support the patient
should a complication arise.
From the plastic surgeon’s perspective, careful analysis
and planning are essential for producing a good outcome
with the greatest chance for longevity in the setting of
reoperation following a previous breast augmentation.
Implant Too Lateral 121
Medial Malposition 126
The Double Bubble Deformity 128
Treating the Double Bubble 128
Ripples, Ridges, Folds, and Implant Edge
Palpability 128
Theories on the Etiology of the Problem 129
Frequency of the Problem 132
Minimizing Skin Wrinkling 132
Surgical Treatment of Ripples, Ridges, and
Folds 132
Capsular Contracture 134
Early Capsular Contracture 136
Established Capsular Contracture 136
Summary Statement on Capsular Contracture
140
Implant Failure—Rupture or Deflation 140
References 142

66
Reoperative Plastic Surgery of the Breast
THE SCOPE OF REOPERATIVE
SURGERY FOLLOWING BREAST
AUGMENTATION
The incidence of reoperative surgery following the place-
ment of an implant, for either breast reconstruction or
breast augmentation, is significant. This has been docu-
mented by numerous published studies.11–17 The reopera-
tion rate at 5 years for breast augmentation—documented
by Gabriel et al.7 in a study of 1,800 patients at the Mayo
Clinic—was 12% at a 5-year follow-up, while 34% of
patients who underwent implant placement for breast
reconstruction required reoperation during that same time
period. Additional studies have found reoperation rates of
15% to 20% following silicone gel breast augmentation.12,13
At the height of the concern about safety issues regarding
breast implants in the early 1990s (popularly termed the
“breast implant crisis”),3 this rate was even higher because of
the number of women requesting removal of their implants.
After April of 1992 plastic surgeons in the United States
were confined to the exclusive use of saline implants for
primary breast augmentation.3 Data relating to this expe-
rience were collected by various authors and the implant
manufacturers.13–17 Once again, when one surveys the
incidence of reoperation in this group of patients, the risk
during the first 3 to 5 years is high. The Mentor
Corporation,16 in a prospective premarket approval study,
reported an incidence of reoperation in 13% during the
first 3 years following saline implant breast augmenta-
tion. Similarly the McGhan Corporation in its study
(AR95)17 reflected a 21% risk of reoperation at 3 years.
A benchmark prospective, longitudinal study of saline
breast implants published14 and updated15 demonstrates a
26% incidence of reoperative surgery within 5 years of
saline implant placement for breast augmentation.
Additional studies, including that of Young et al.,13 dis-
close a high rate of reoperation in the form of explanta-
tion (24%) within 7 years of breast augmentation surgery,
with many patients requiring more than one explantation.
The most common reasons cited for explantation in these
studies include capsular contracture, rupture or deflation,
asymmetry, inadequate size, and patient request for
implant change.13
A new source of data on the outcome of saline breast
implant placement is the Saline Breast Implant Registry
(NaBIR), which was begun in 2000,18 largely through the
efforts of Dr. V. Leroy Young in conjunction with the
Plastic Surgery Educational Foundation. It is a confiden-
tial registry of data submitted by plastic surgeons on
saline implant placement for either breast augmentation
or reconstruction that allows prospective tracking and
comparison of results in an identifiable cohort of patients.
The data compiled thus far again indicate that the reoper-
ation rate for explantation is significant (15.4%) within
the first 4 years following surgery.
From the foregoing studies it is apparent that reopera-
tion following a previous breast augmentation is com-
mon. Furthermore, it is my opinion that the revision rate
is too high for an elective cosmetic surgery procedure.
A significant portion of these reoperations are attribut-
able to implant-related factors and therefore they are
probably not preventable with the implants that are cur-
rently available for use. However, problems leading to
early revisions (e.g., those due to size change and opera-
tions done to treat implant malposition and some asym-
metries) are most likely due to inadequate preoperative
communication with the patient, improper analysis of
patient anatomic features, and incomplete preoperative
planning and/or errors in surgical technique. I am firmly
convinced that the rate of reoperation for the conditions
just mentioned can be reduced by better preoperative
planning and more consistent technical performance of
the operation. Said another way, it seems apparent to me
that such problems are best addressed by prevention. This
view is shared by other authors as well.19,20
Toward this goal, I have adopted a methodical
approach to the evaluation of the prospective patient seek-
ing breast augmentation. This includes taking a careful
history with an emphasis on size concerns and conducting
a thorough physical examination with an anatomic and
aesthetic analysis, which results in an individualized sur-
gical plan for implant selection and the surgical approach.
The procedure is performed with an awareness of the
patient’s particular anatomy using mainly the electro-
cautery with minimal gentle blunt dissection of the lateral
pocket as described. The goal is to achieve precise pocket
dissection that will fit the chosen implant. This approach
has been successful in my hands from the standpoint of
decreasing the incidence of short-term problems related
to doctor–patient communication (implant selection),
inadequate planning, and technical errors. The details of
this approach are described in the following section.
Subsequently, my approach to revision of breast augmen-
tation is discussed.
AN APPROACH TO PRIMARY BREAST
AUGMENTATION—PATIENT
EVALUATION AND DECISION MAKING
As in all of medicine, the interaction with the patient
begins with a careful history and physical examination.
This also applies when approaching the prospective breast
augmentation patient. Careful attention must be paid
to the patient’s chief complaint or desires regarding the
operation, her anatomic features, and her breast develop-
ment. The latter is investigated regarding whether the
breast development has been symmetric. The patient’s
personal history of breast problems, e.g., pain, menstrual-
cycle–related breast variations, and history of breast

masses, with any family history of breast cancer, is thor-
oughly investigated.
It is important to inquire about any lumps or masses
that the patient may have had in either breast during the
course of her lifetime and what the treatment of these
was. Specifically, it is important to determine exactly what
the diagnosis was and how it was resolved. In patients
who are older than 35 years of age the physician must
inquire about whether the patient has had a mammo-
gram, and if so the results of the study must be known. I
find it helpful to personally review these mammograms—
often with the help of a radiologist. If the patient has not
had a mammogram by this age, one should be ordered.
It is very important for the physician to understand, in
as much as is possible, the patient’s desires relating to
breast size. If a patient has been pregnant, I find it helpful
to ask how large the breasts became during pregnancy and
whether the patient was comfortable with or enjoyed the
size of her breasts during her pregnancy. To help me better
understand the patient’s desire for size and appearance of
the breast following surgery, I prefer to have the patient
bring in pictures of normal patients (not models) with sim-
ilar body types who have an appearance that they find
attractive and desirable. This gives me an insight into the
look that the patient is after. Such photos are available on a
variety of websites (Fig. 3-1).
Similarly, in the setting of a previous pregnancy, it is
important to inquire about the changes in the breast fol-
lowing such pregnancies. Many patients are bothered by
the loss of volume and the change in shape that has
occurred. Carefully noting the patient’s opinion regarding
breast settling or ptosis is important, and when appropri-
ate, suggestions regarding breast ptosis correction in con-
junction with breast augmentation should be made. I am
increasingly performing a mastopexy in conjunction with
an augmentation in this population of patients, especially
as part of a revision procedure. If the plan entails a
mastopexy, I believe that it is critical to discuss the posi-
tion of scars, the fact that they will be permanent, and the
fact that recurrent breast ptosis is part of the picture with
every mastopexy—including augmentation mastopexy. I
find that this operation carries a higher risk of complica-
tions than either of these procedures performed sepa-
rately.
Systematic examination of the breast is carried out as
described in Chapter 2. The surgeon should note the gen-
eral appearance of the breasts, scanning them for symme-
try in terms of contour, fullness, nipple areola position,
and the position of the breast relative to chest wall struc-
tures. Both obvious and subtle asymmetries are noted. As
alluded to previously, I find it helpful to measure the
dimensions of the breast, including the base width, height
(the extent of upper pole fullness when the breast is gently
compressed against the chest wall), and various distances
of the breast architectural features from a fixed point on
the torso. Most often I find it helpful to measure the dis-
tance from the nipple to the suprasternal notch (SSN) on
each side, followed by the distance of nipple to the infra-
mammary (IM) fold in the midmeridian of the breast and
also the distance from the inferior aspect of the NAC to
the IM fold. I record all these measurements on a breast
diagram or a worksheet I use for breast augmentation in
the patient’s chart (Fig. 3-2).
After performing a complete and systematic examina-
tion, I discuss with the patient the potential incisional and
implant position options. The incisional approaches I use
are the IM (60%), transaxillary (30%), and periareolar
(10%) (Fig. 3-3). All of these incisional approaches can
work well in the appropriate situation and usually leave
inconspicuous scars. Patients often have a preference for
which scar position they would like, and it is usually pos-
sible to accommodate their wishes. Exceptions would be
grade II or greater ptosis in a patient who desires a
transaxillary breast augmentation.
CHOOSING AN IMPLANT
The choice of implant is patient specific. Most patients
who undergo breast augmentation in the United States
seek a breast volume increase of two cup sizes.1 Concepts
about breast attractiveness relative to size are different in
different cultures, with women in Europe21 and South
America21 in general desiring less breast volume enhance-
ment from a breast augmentation. I try to listen very
intently to every idea and intention a particular patient
has about her perceived postoperative size. I have come to
understand that what patients want and find desirable is
often very different than what the plastic surgeon consid-
ers to be an aesthetically desirable result. As previously
mentioned, reviewing photographs brought in by the
patient can yield an important insight into a particular
patient’s desires and expectations for both volume and
shape following breast augmentation.
Preoperative planning and implant selection depend to
a significant degree on patient anatomic factors including
breast dimensions, torso dimension, degree of ptosis, pre-
existing asymmetry(ies), and tissue quality, including elas-
ticity, thickness, and ability to stretch.20 In my practice
implant selection is governed mostly by anatomic surface
relationships, and I key into breast and torso dimensions.
The most important is the base width (Fig. 3-2) of the
breast, or the distance from the area immediately lateral to
the lateral edge of the sternum to the lateral silhouette of
the breast. This distance determines the largest base width
of the implant that can be placed, especially if a round
implant is selected. The center of a round implant should
be positioned beneath the nipple. If the implant has too
great a diameter (is too large dimensionally), then the
breast will elongate vertically or produce an abnormal
Chapter 3
Revising the Unsatisfactory Breast Augmentation
67

68
Reoperative Plastic Surgery of the Breast
FIGURE 3-1. Example of downloaded photographs from a
website illustrating, A, preoperative appearance of the breasts
in an augmentation patient. B, The smaller breast implant and,
C, larger breast implant in the same patient.

Chapter 3
Revising the Unsatisfactory Breast Augmentation
69
FIGURE 3-2. Worksheet illustrating topographical relationships of the breast to the chest wall. Note
relationship of suprasternal notch (SSN) to nipple and nipple to IM fold. Also note distance from the
lower areola to the IM fold.

horizontal contour. A helpful rule of thumb is that when
using a round implant the largest radius that should be
used is equal to the distance from the nipple to the ipsilat-
eral parasternal take-off of the breast (Fig. 3-4). This is
because the tissues between the nipple and the parasternal
area are fixed. The height of the implant is also important,
but because the IM fold is often lowered the accommoda-
tive height can vary. The distance from the nipple to the
lateral silhouette of the breast on anteroposterior (AP)
view is also variable due to the distensibility of those tis-
sues. Therefore, the horizontal distance from the nipple to
the parasternal region represents the greatest implant
radius that should be selected when a round implant is
used. I will generally choose an implant that is smaller in
dimension than this distance.
The distance from the midclavicular point to the nipple
and the distance from the SSN to the nipple are also
important dimensions, and they are recorded on the pre-
operative worksheet (see Fig. 3-2). After carefully record-
ing these dimensions, I consult various implant charts
provided by the manufacturers to select an implant that
will best satisfy the patient’s desires and fit her anatomy
(Fig. 3-5A–B).
If there are other anatomic considerations, such as
petite or small stature or narrow torso, it is often desirable
to select an implant with more volume for a given base
dimension. In such a patient a high-profile implant (one
with greater projection and volume for a given base diam-
eter) may be helpful (Fig. 3-6A,B). Such implants are very
helpful in patients who place a premium on a large vol-
ume in the face of smaller breast and torso dimensions.
Alternatively, a shaped textured implant can be used.
These implants are designed with variable heights and
volumes for a given base width, and they give the illusion
of greater projection and volume for a given base diameter
dimension (Fig. 3-6C). I use a shaped implant with a rela-
tively short vertical dimension in patients of small stature
who desire a very full breast.22 Conversely, I have found
that shaped implants that have a long vertical dimension
may be helpful in the very tall patient (greater than 6 feet
in height) who require tapered upper pole fullness as part
of their augmentation.
Although most plastic surgeons acquire the majority of
their individual experience with a certain style or type
of implant (I prefer a smooth round implant for most
patients seeking breast augmentation), the surgeon must
have experience with and facility using various types of
implants. This permits using the most individualized
approach with each patient.
IMPLANT POSITION
The two alternatives for implant position are either the
subglandular or the submuscular space (Fig. 3-7A–B).
The choice, again, depends on the patient’s anatomy, sur-
geon analysis, and a combination of patient and surgeon
preference. Placing the implant in the subglandular space
simplifies the procedure in terms of the dissection, is
associated with less postoperative discomfort, and gener-
ally results in a quicker recovery.23 This position for the
implant is especially good for patients who have glandular,
grade I, and some mild forms of grade II mammary ptosis.
70
Reoperative Plastic Surgery of the Breast
FIGURE 3-3. Incisional approaches I use for breast augmenta-
tion.
FIGURE 3-4. Measurement of nipple to parasternal area yields
maximum possible radius if a round implant is selected.

Chapter 3
Revising the Unsatisfactory Breast Augmentation
71
FIGURE 3-5. Charts for surface dimensions and volume of various implants manufactured by the
Mentor (A) and the McGhan Corporation (B).

72
Reoperative Plastic Surgery of the Breast
For the surgeon to use this position, the patient must have
sufficient upper pole breast tissue to cover or camouflage
the edges of the implant. I determine the adequacy of the
tissue in the upper part of the breast by using the pinch test
as described by Tebbetts.22 I too believe that there should
be at least 2.5 cm of tissue in the upper pole of the breast to
adequately conceal a subglandular implant (Fig. 3-8). If
there is not, it is best to use the subpectoral position for
implant placement—especially if a saline implant is
selected because this type of implant has a definite
predilection for visibility and palpability. The major disad-
vantages of the subglandular position of an implant are
that there is an increased risk of capsular contracture24,25
and that mammograms are less sensitive,26 i.e., more of the
breast tissue is hidden. Finally, the dissection to place an
implant in the subglandular space results in greater
decrease in the blood supply to the remaining breast
parenchyma with the division of many perforating vessels
from the pectoralis major muscle (PMM; Fig. 3-9A,B).
In this era of saline implants, by far the most common
position is the submuscular or, more precisely stated, a
partial retropectoral position for the implants (see Fig. 3-
7B). This is because such positioning will maximally cam-
ouflage any type of irregularity related to the implant edge
or changes in implant shape related to the distribution of
the sterile saline filler substance within the implant. In
addition, subpectoral placement is associated with a
decreased incidence of capsular contracture regardless of
implant type.24 Finally, the subpectoral position affords
the best possible breast surveillance in terms of postoper-
ative mammograms.26 This may be an important consid-
eration for many patients, and increasingly I find it to be a
particular advantage. The dissection is a little more tech-
nically demanding, and it most often involves the release
of the origin of the PMM from the fifth and sixth ribs
(Fig. 3-10). After the release of this portion of the muscle,
the inferior aspect of the breast implant sits beneath the
lower pole of the breast, or even beneath the subcutaneous
tissue in those patients who have a lowering of their previ-
ous IM fold. There is also more postoperative discomfort
associated with this approach than that seen following
subglandular placement of a breast implant.
FIGURE 3-6. A, Standard profile and similar volume high-profile implant. There are important differ-
ences in volume and projection for a given base dimension. These dimensional and volume differences
often play a significant role in revision of a previous breast augmentation. B, Implants have either a smooth
or textured (right image) surface. C, Shaped textured implants available as saline or silicone devices.
FIGURE 3-7. A-B, Breast implants can be positioned in the sub-
glandular or submuscular position. Implants in the submuscular
space are covered by muscle in only their upper 70%. The lower
30% sits behind the breast gland or in the subcutaneous position.

Chapter 3
Revising the Unsatisfactory Breast Augmentation
73
FIGURE 3-8. Pinching upper pole of the breast parenchyma is
an accurate way of estimating the thickness of the breast tissue
in that region.
FIGURE 3-9. A, Blood supply to the breast parenchyma is derived from various sources. B,
Subglandular implant placement results in a substantial decrease in the blood supply to the breast
parenchyma and NAC.
FIGURE 3-10. Release of part of the origin of the PMM from
the fifth and sixth ribs in the lower aspect of the breast.

74
Reoperative Plastic Surgery of the Breast
SELECTION OF INCISION
In my current practice the incisions I offer to patients are
the inframammary (IM), infra-areolar, and axillary. I cur-
rently do not perform transumbilical breast augmentation.
The IM incision is the most commonly used and most ver-
satile of the incisions used for breast augmentation. This is
reflected in my practice and by data recorded in NaBIR.18 It
provides direct visualization of the subglandular and sub-
pectoral planes and offers the most direct approach for man-
aging any problems in the lower pole such as IM fold
asymmetries. This incision has a tendency to ride up on the
implanted breast as the implant settles, and therefore it
should be positioned adequately low or approximately 1 to 2
mm below the intended level of the new IM fold. A careful
three-layered closure of the wound, which includes the tis-
sue adjacent to the implant, the deep dermis, and an intracu-
ticular apposition of the skin wound, is routinely performed.
INFRA-AREOLAR INCISION
The infra-areolar incision is also commonly used. It
also affords excellent access to the lower pole of the
breast, whereby the surgeon can address asymmetries
or treat discrepancies or constriction of the IM fold. It
can be incorporated into a periareolar incision, thereby
making it an excellent choice for cases that are likely to
include an augmentation mastopexy. It is also very use-
ful for treating patients with a constricted breast defor-
mity (Fig. 3-11) because it allows a setback of the
pseudo-herniation of the NAC, which is a salient feature
of that deformity. The incision should be placed in the
junction of the more darkly pigmented areolar skin and
adjacent breast skin. In this position it is less conspicu-
ous. Placing it within the areola itself may result in visi-
bility due to potential hypopigmentation of the
resulting scar. Access to the subglandular or subpec-
toral space is attained by dissecting directly through the
breast parenchyma or by inferior elevation of a breast
skin flap above the breast fascia and entrance into
either of these planes from below (Fig. 3-12A,B). I pre-
fer to dissect through the breast parenchyma as this
route provides a direct exposure to either plane. The
incision often yields excellent cosmetic results, but it
may result in a slightly greater chance for decreased
nipple sensibility.
FIGURE 3-11. Constricted breast deformity (oblique view) is
best approached through periareolar incision.
FIGURE 3-12. A-B, Dissection using periareolar incision is
done either around the lower pole of the breast or directly
through the breast parenchyma.

Chapter 3
Revising the Unsatisfactory Breast Augmentation
75
AXILLARY INCISION
The transaxillary approach to breast augmentation
avoids a scar on the breast, and in my practice it is
a popular approach for young unmarried women.
I believe that the incision should be positioned trans-
versely, and I generally tend to place it in or just above
the highest skin crease in the axilla. It should be kept
posterior to the posterolateral edge of the PMM and
anterior to the latissimus dorsi muscle (Fig. 3-13A,B).
The incision should be limited to between 3.0 and
3.5 cm. With this approach the skin should be under-
mined for a distance of 2 cm in both an anterior and
inferior direction, and dissection through the clavipec-
toral fascia gives access to the subpectoral space. The
resulting scar is almost always inconspicuous by 1 year
following surgery. There is an incidence of numbness
and paresthesias involving the upper inner arms related
to retraction of or injury to the intercostal brachiocuta-
neous nerves, but in my experience this is less than 5%.
In every case of transaxillary breast augmentation I
inform the patient preoperatively that should she require
re-exploration for bleeding or other problems, this will
usually require another incision on the breast, either in
the IM fold or infra-areolar area.
Information about the options just discussed is pre-
sented to the patient in an interactive format to encourage
active participation in the decision-making process on the
part of the patient. During this time instructions regard-
ing postoperative care are also given to the patient.
Finally, a detailed enumeration of the potential risks and
complications concerning breast augmentation is pre-
sented to the patient. During this discussion we empha-
size that a breast implant will in all likelihood not be a
lifetime device and that the two most common inherent
risks following this operation are those of capsular con-
tracture and the need for reoperative surgery on the
breast(s) at some point in the future.7 A sample of the con-
sent form I use for primary breast augmentation is shown
in Appendix A of this chapter Finally, we discuss cost
implications regarding unplanned reoperative surgery
after breast augmentation (surgeon’s fees, facility charges,
and anesthesia fees), both in the rare circumstance of sur-
gery done immediately following the procedure (e.g., to
drain a hematoma) or surgery undertaken at a later date.
Once decisions about the type of implant, position of
the implant, and selection of incision have been made, the
patient must decide whether to proceed with surgery. I
find that there is a high patient sign-up rate (>80%) for
patients I see in consultation for breast augmentation.
FIGURE 3-13. A, The appropriate incision for a transaxillary augmentation is high in the axilla and
lies posterior to the posterior edge of the PMM and anterior to the latissimus muscle. B, The high axil-
lary scar heals well and is barely perceptible at 1 year following surgery.

76
Reoperative Plastic Surgery of the Breast
SURGICAL PLANNING AND
TECHNIQUE
There is no doubt in my mind that careful preoperative
planning and precise, consistent pocket dissection are
important in every breast augmentation. Furthermore,
I strongly believe that the incidence of immediate postop-
erative and short-term problems (implant malposition
and palpability, breast asymmetry), and perhaps long-
term problems as well (implant rupture or deflation and
even capsular contracture), following breast augmenta-
tion can be reduced by individualized surgical planning
and consistent technique.
The patient is carefully marked before surgery in the
upright position to ensure precise pocket dissection and
placement of incisions. Outlines of the existing IM fold
and breast base width are inscribed on the skin. Next, the
precise position of implant placement is noted
(Fig. 3-14A). If the IM fold is to be lowered, the exact
extent of this lowering is noted (Fig. 3-14B). I do not dis-
sect the largest possible pocket because this may predis-
pose to implant malposition. To create a more precise
pocket I next outline the extent of superior pocket dissec-
tion. I find it helpful to have the patient compress her
breast gently against the chest wall, and in this way the
most superior aspect of the breast is apparent (Fig. 3-15).
To limit the possibility of excess medial dissection I next
draw a vertical line in the middle of the sternum. Then I
draw two additional lines, one on either side of this first
line 1.5 cm lateral to it over the lateral sternal area
(Fig. 3-16A). These lines denote the medial-most extent
of the dissection (Fig. 3-16A). I do not dissect medial to
them. I have found that this will minimize the possibility
of creating medial implant malposition (symmastia if it
is seen bilaterally). The midaxillary line on the lateral
chest wall should be noted. This vertically oriented line
FIGURE 3-14. A, Outline on the patient’s skin of the IM fold and proposed position of the implant is
noted. B, Outline of proposed lowering of the IM fold is also marked on the skin. Note that the position
of the incision is off the patient’s breast.
FIGURE 3-15. The superior extent of the patient’s breast tissue
is noted by gently compressing the breast against the chest wall.

Chapter 3
Revising the Unsatisfactory Breast Augmentation
77
lies midway between the lateral border of the PMM and
the anterior edge of the latissimus dorsi muscle, which
can be easily appreciated in most patients (Fig. 3-16B). I
do not dissect lateral to this point. Limiting the extent of
lateral pocket dissection is an important factor in limit-
ing the likelihood of lateral implant malposition.
Planning the surgery in this way provides a guide to
precise pocket development. In my hands the combina-
tion of planning and consistent surgical technique opti-
mized postoperative breast symmetry and has limited the
occurrence of breast asymmetry and implant malposition
and early reoperations related to them.
FIGURE 3-16. A, Vertical midsternal line drawn from SSN to xyphoid. Lines are drawn 1.5 cm lateral
to this line on each side, and the medial dissection should not proceed medially to this line. B, The lat-
eral dissection should not go beyond the midaxillary line. This will minimize the frequency of lateral
implant malposition.
FIGURE 3-17. One-year postoperative AP (A) and oblique (B) views of the patient noted in Figure 3-14.

78
Reoperative Plastic Surgery of the Breast
The 1-year postoperative results of the patient noted in
Fig. 3-14 on AP and oblique views is illustrated in Fig. 3-17
A, B).
POCKET DISSECTION
Dissection of the pocket for implant insertion should be
done in a gentle manner with attainment of meticulous
hemostasis. I perform almost all of the dissection under
direct vision with the electrocautery with the exception of
the lateral aspect of the pocket, which is performed last
with gentle digital dissection (Fig. 3-18) after the sizer has
been positioned. Minimal, blunt gentle digital dissection
minimizes injury to the lateral sensory nerves and the pos-
sibility of lateral implant subluxation (Fig. 3-18) while
allowing me to maximize the medial fullness or cleavage.
The lateral sensory nerves very often can be palpated
and/or directly visualized. Most recently when I have visu-
alized the nerves through an IM incision, I have occasion-
ally performed this lateral pocket dissection with the
electrocautery, dividing tissue adjacent to the nerves with
minimal danger of injuring them.
When using a saline implant sizer I inflate this device
with air in situ using a one-way valve. The maneuver is
carried out with the patient placed in the sitting position
at 90 degrees on the operating table (Fig. 3-19). Most often
I use implant sizers to assess the adequacy of pocket dis-
section and breast contour rather than to establish which
size implant I will choose. This decision is usually estab-
lished before the operation.
SUBGLANDULAR POCKET DISSECTION
The subglandular space is easily dissected through either
an IM or infra-areolar incision using a headlight or
lighted retractor. I perform the dissection inferior to
medial to superior according to the preoperative skin
markings. The lateral dissection is initially limited. I
then place an OpSite dressing on the skin to eliminate
contact of the implant with the patient’s skin and associ-
ated skin flora (Fig. 3-20A). The sample sizing implant or
the implant to be used for the procedure is inserted
through an incision made in the OpSite (Fig. 3-20B).
Before inserting this device I analyze this implant sizer
for its base dimension by measuring it. In addition, both
pockets are irrigated with a solution containing 50,000
IU of bacitracin, 500 mg cefazolin (Ancef), and 80 mg
gentamicin in 1,000 cc of sterile saline intravenous (IV)
fluid.27
The symmetry of the breasts, including implant posi-
tion and inferior level of the implants, is checked with
both implants in place while exerting gentle downward
pressure on the upper poles of the breast (see Fig. 3-19).
This maneuver is very helpful in minimizing asymmetries
of the IM-fold level of the augmented breasts.
When I am completely satisfied with the implant posi-
tion and breast appearance, I perform a three-layer clo-
sure of the wound as described earlier, applying a
circumferential dressing consisting of both a Kerlix (Tyco
Healthcare Group, Mansfield, Mass) roll application and
Ace (Becton Dickinson, Franklin Lakes, NJ) wrap. The
dressing remains in place for approximately 3 days, at
which time the patient is taken out of her dressing and
switched to a sports bra. Bra support of the breasts is
maintained for 1 month following surgery. When an IM
incision is used, I request that patients refrain from using
an underwire bra for 3 months to minimize any adverse
effect on the incision.
SUBPECTORAL POCKET DISSECTION
The subpectoral space can be developed using any of the
incisions described earlier. From the IM approach I iden-
tify the lower pole of the breast tissue and gently sweep it
superiorly using the electrocautery set to the coagulation
mode. This allows identification of the lateral border of
the PMM, and the plane beneath it is easily entered under
direct visualization (Fig. 3-21A). This plane is developed
with electrocautery dissection directed superior-medially
toward the NAC. A narrow Deaver retractor is then
inserted and the remainder of the dissection is performed
with the electrocautery. The origins of the PMM are
released on its deep surface along the length of the lower
aspect of the breast proceeding from lateral to medial,
establishing the desired inferior position of the implant
pocket. The PMM is completely released in most cases to
the parasternal area (Fig. 3-21A). The exception to this is
the exceedingly thin patient in whom the muscle is
released but the pectoralis fascial layer is maintained
intact by gently stretching this layer with blunt dissection.
This provides an additional layer of tissue to pad the
implant in the lower breast. More important, this layer
may help to support the weight of the implant. Along the
lateral sternal area the PMM is not divided but rather it is
attenuated on its deep surface (Fig. 3-21B). Releasing the
muscle here can produce an abnormal contour, often lead-
ing to a step-off along the lateral sternum that is difficult
to correct.
Instead the medial PMM is attenuated on its deep sur-
face (Fig. 3-21B). This is accomplished by scoring the
muscle on its deep surface with the electrocautery set to
the coagulation mode. The deep muscle surface is gently
touched in a doting-type fashion. The depth of the dissec-
tion within the deep surface of the muscle is usually 3 to 5
mm. This attenuation of the PMM allows a favorable
drape over the implant and produces the best possible
cleavage when the subpectoral position is chosen for

Chapter 3
Revising the Unsatisfactory Breast Augmentation
79
FIGURE 3-18. Lateral dissection is performed with gentle digi-
tal dissection to maximally preserve the sensory nerves to the
nipple.
FIGURE 3-20. A, Sterile OpSite barrier drape is placed over the incision on patient’s skin before
implant insertion. B, The implant is inserted through an opening in the barrier drape.
FIGURE 3-19. Following insertion of the implant, the lower
poles of the breasts are inspected for symmetry by applying gen-
tle pressure over the upper poles of the breasts with the patient
sitting at 90 degrees on the operating table.

80
Reoperative Plastic Surgery of the Breast
FIGURE 3-21. A, Release of inferior origin of the PMM from the
lateral edge of the muscle to the lateral sternal edge. B, The PMM
is attenuated on its deep surface with a superficial incision into
the deep surface of the muscle with the electrocautery device
along the sternal margin.
breast augmentation. I believe that detaching the medial
or parasternal PMM should be avoided, and this view is
shared by others.28 Next, the superior extent of the pocket
is established. The lateral dissection is initially limited.
The dissected pocket is then irrigated with the antibiotic
solution noted earlier. A sizer is placed as noted earlier,
and the final adjustments to the lateral implant pocket are
completed with the patient in the sitting position using
gentle digital dissection (see Fig. 3-18). Very often the sur-
geon will feel the lateral intercostal nerves as transverse
bands. These can be slightly stretched, but they must be
preserved intact. Once again, the lateral dissection should
never be carried posterior to the midaxillary line. This line
is also routinely drawn on the patient’s skin preopera-
tively. The final breast appearance is checked with sizers
in both implant pockets, and if it is completely satisfac-
tory, implants are inserted and then the incision is closed
in three layers.
The subpectoral space can be developed through the
infra-areolar incision by dissecting through the breast
parenchyma and splitting the medial PMM in the direc-
tion of its fibers. This provides immediate and excellent
access to the underside of the PMM, and release of its ori-
gin from the fifth and sixth ribs can be accomplished as
outlined in the preceding paragraph. The remainder of the
procedure is as outlined earlier.
When using an axillary incision, standard markings are
used (Figs. 3-13A and 3-22A). I currently prefer using
endoscopic assistance to perform the PMM release from
its origin on the fifth and sixth ribs inferiorly as opposed
to using blunt dissection. As noted earlier, after the inci-
sion is made the skin is undermined for a distance of 2
cm, and then the dissection is deepened through the
clavipectoral fascia and the lateral border of the PMM is
noted. The muscle fibers themselves are not exposed. The
interval between the PMM and pectoralis minor muscle is
directly visualized, and the subpectoral plane is developed
by gentle blunt dissection with an Agris-Dingman dissec-
tor inferiorly toward the origin of the PMM. A special bal-
loon dissector is inserted and inflated to create the optical

Chapter 3
Revising the Unsatisfactory Breast Augmentation
81
cavity. I have found that a sample sizing implant works
equally well for this maneuver. Next the endoscope is
inserted, and operating through the same transaxillary
incision the origin of the PMM is visualized (Fig. 3-22B).
This technique provides a controlled release of the muscle
(Fig. 3-22C) and can also facilitate hemostasis. The final
inferior dissection to establish the inferior aspect of the
implant pocket is done with the Agris-Dingman dissector.
After completing the dissection of both pockets, the space
is irrigated with a solution containing 50,000 IU of baci-
tracin, 500 cc cefazolin (Ancef), and 80 cc gentamicin in
1,000 cc of sterile saline IV fluid27 and the sample sizing
implants are placed. Symmetry between the breasts is
checked with the patient in the sitting position. I find that
it is helpful to gently compress the upper poles of the siz-
ers to ensure symmetry of the lower aspect of the breasts
(see Fig. 3-19). When the appearance of the breasts is
completely satisfactory, the implants are inserted and the
axillary incision is closed in two layers, including the deep
dermis and skin wound. I prefer to approximate the skin
incision with 5-0 nylon sutures. A similar dressing to that
described earlier is placed.
POSTOPERATIVE MANAGEMENT
Following the procedure, patients are generally managed
with a period of abstinence from heavy exercise of
approximately 6 weeks. They are started on a program of
implant displacement exercises (Fig. 3-23A–C) on postop-
erative day 1 or 2 when a smooth-walled implant is used
according to their comfort level. The purpose of this
FIGURE 3-22. A, Preoperative AP view of transaxillary endo-
scopic-assisted augmentation mammoplasty patient. B, PMM
origin revealed under endoscopic visualization. C, Postoperative
AP view at 6 months following surgery.

82
Reoperative Plastic Surgery of the Breast
treatment is to maximize the mobility of the implant and
the distensibility of the periprosthetic capsule. I person-
ally believe that this maneuver helps keep the implant as
soft as possible, and it may limit the occurrence or extent
of capsular contracture. This opinion is shared by many
plastic surgeons.29,30 More important, this maneuver is
something that the patient can do to help her recovery
and preserve the softness and natural feel of her result.
FOLLOW-UP CARE
In addition to the displacement exercise regimen, we
emphasize the importance of clinical breast examina-
tions31 (CBEs) to all patients. More important than this
is long-term physician follow-up examinations. I offer
patients yearly follow-up visits for the rest of their lives at
no charge to them. I do this so that I can be satisfied that
they are being examined by a physician who is experienced
in the examination of the breast that has undergone an
augmentation. Most important, we recommend postopera-
tive mammograms on the schedule as prescribed by the
American Cancer Society.32 Mammography remains the
most accurate way of making the diagnosis of breast can-
cer. In breast augmentation patient, special views that
involve displacing the implant are routinely employed.33
When this technique is employed, implant-related compli-
cations are rare.34 Although there is a decreased sensitivity
of mammograms following breast augmentation,26,35 there
is no evidence that the diagnosis of breast cancer is made
at a later stage in patients in patients who have undergone
breast augmentation when compared with patients who
have not undergone breast augmentation.34–36
REVISION OF BREAST
AUGMENTATION—HISTORY AND
PHYSICAL EXAMINATION
See Table 3-1.
As previously noted, revision of a previous breast augmen-
tation is not an uncommon operation.7,11–17 When patients
present for such surgery, they are almost always a number
of years removed from their previous procedure(s). In this
setting, the surgeon must be very clear about exactly what
is bothering the patient. Again, this understanding comes
from a very careful history of not only the previous sur-
gery(ies), but also any changes that have occurred since
the time of her last operation. A good deal of time must
be spent with each patient seeking a revision of a previ-
ous breast augmentation to understand her particular
problem and to formulate the best possible treatment
plan. The surgeon must communicate with the patient,
emphasizing realistic goals, limitations, and potential
FIGURE 3-23. Implant displacement exercises following breast
augmentation. A, Medial displacement. B, Lateral displacement.
C, Vigorous superior displacement may also be helpful.

Chapter 3
Revising the Unsatisfactory Breast Augmentation
83
complications. This will build the best possible
doctor–patient relationship that I find so helpful during
the recovery from additional surgery—especially if there
are additional complications.
I always ask the patient if she was happy after the
original operation. Her response often not only gives me
insight into her specific complaints or concerns about
the augmentation procedure, but also reflects the
patient’s general sense of satisfaction and can be an indi-
cation of whether she can be content with the results of
additional surgery. Comments such as “they were never
large enough,” or “they were always so hard,” or “they
never felt natural” can be very telling, especially if the
physical inspection of the breast and the examination is
at variance with these comments. Occasionally the
patient will make an unsolicited comment about her
previous surgeon or surgeons, and this too may provide
some insight as to whether I will be able to achieve an
improvement in her situation with which she will be
happy.
The patient’s chief complaint should be as focused as
possible. Is the patient bothered by the size, lack of supe-
rior fullness, or any asymmetry (i.e., of the shape, con-
tour, IM fold level or definition of the fold, or position of
the implants)? It is important to understand the patient’s
feelings about her nipple position, the degree of firmness
of the implant, and the relationship of the breast
parenchyma to the implant. Is there evidence of signifi-
cant capsular contracture? Are there problems with
implant edge palpability, obvious folds that show
through the skin, or implant malposition? When such
malpositions (e.g., lateral, superior, inferior, or medial
displacement of the implant) exist, they may be
increased in certain postures or positions. If there are
◗TABLE 3-1 Overview of Reoperative Breast Augmentation
1. Gather patient history
a. Breast development
b. Changes in breast volume and appearance with menstrual cycle
c. Breast cancer history
d. Family history of breast cancer
e. Previous breast surgery(ies)
f. Breast pain
g. Nipple sensitivity
h. Mammogram history
2. Identify specific patient desires
a. What exactly bothers the patient
b. Is she satisfied with size, fullness, shape
c. Is there capsular contracture
d. What is status of nipple areolar symmetry
3. Examine the patient
a. Amount of breast tissue
b. Distribution of breast tissue
c. Scars on the breast
d. Breast skin appearance and elasticity; presence of striae
e. Thickness of subcutaneous tissue and breast parenchyma
(tissue “padding”)
f. Dimensions of breast
i. Base width
ii. Breast height when chest is gently compressed
iii. Nipple to IM fold distance
iv. SSN to nipple distance
v. Midclavicle to nipple distance
g. Position of breast on chest wall; cleavage: wide or tight
h. Capsular contracture
i. Presence and degree
ii. Baker classification (I–IV)
i. Implant visibility: ridges, ripples, folds
j. Implant edge palpability
k. Ptosis: relationship of nipple to breast tissue
i. Grade of ptosis
ii. Relationship of breast tissue to underlying implant
l. IM fold development: any element of constriction
m. Asymmetry
i. Breast volume or volume distribution
ii. Contour
iii. Nipple areola height, size, inclination
n. Chest wall deformity: pectus excavatum
i. Ribs
ii. Pectoralis muscles
o. Scoliosis
4. Diagram the breasts: breast worksheet
5. Create photographic documentation
a. AP/lateral/oblique
b. Special views: lying down, bending forward
6. Collect implant data
a. Chronology of operations
b. Incisional approaches
c. Size
d. Type
e. Position
7. Collect breast imaging data
a. Mammogram/sonogram
b. MRI
8. Make diagnosis and formulate plan
9. Propose surgical approach to patient
10. Review informed consent
11. Proceed with surgery if appropriate
IM, Inframammary; SSN, suprasternal notch; AP, anteroposterior; MRI, magnetic resonance imaging.

84
Reoperative Plastic Surgery of the Breast
particular positions that bother the patient, specific
descriptions of these circumstances should be eluci-
dated. Is there pain or discomfort in the breast(s)? The
etiology of such breast pain or mastodynia in the setting
of a previous breast augmentation is often difficult to
establish and most of the time is multifactorial. I most
often tell the patient that there is no surgical solution or
surgical cure for breast pain. Has there been a change in
the appearance of the breast, and if so what is the time
course of the change? Is there a history of previous
implant rupture or deflation of a breast implant, and if
so how was that problem treated?
As I have suggested, it is important to have a complete
understanding of all of the patient’s previous breast pro-
cedures. This includes the chronology of and time inter-
val between the operations, as well as implant types,
sizes, and position of placement. It is important to
inquire about whether any of the procedures were asso-
ciated with acute complications, and if so how these
complications were managed. Any history of trauma to
the breast(s) must be noted. Not uncommonly the sur-
geon will elicit a history of a closed capsulotomy that
was done after a silicone gel breast augmentation. In the
past many patients routinely would undergo such a
manipulation if early firmness of the implant was
detected following breast augmentation.37 This practice
has been documented to be associated with an increased
incidence of breast implant rupture.38,39 Such treatment
of mechanically squeezing the previously augmented
breast is now discouraged and it should no longer be
done.
A systematic examination of the breasts is then carried
out as described in Chapter 2. The surgeon should note
the general appearance of the breasts, scanning them for
symmetry in terms of contour, fullness, nipple areola posi-
tion, and position of the breast relative to the chest wall
structures. Any obvious asymmetries are immediately
noted. Next, more subtle asymmetries are examined. The
relationship of the patient’s native breast tissue to the
implant must be noted. Has there been any settling of the
breast tissue away from the implant?
I find it helpful to measure dimensions of the breast,
including base width, height, and the extent of upper pole
fullness when the breast is gently compressed against the
chest wall. I then carefully measure the distance of the
nipple from the fixed point of the SSN on each side, fol-
lowed by measurements of the distance from the nipple to
the IM fold in the midmeridian of the breast, and also the
distance from the inferior aspect of the NAC to the IM
fold. I then record all of these measurements on a breast
diagram in the patient’s chart (see Fig. 3-2). I find that it is
very helpful to refer to this initial diagram of the breast
whenever I perform any breast surgical procedure. This
diagram is especially helpful when planning a revisional
procedure.
COMPLICATIONS OF BREAST
AUGMENTATION
A simple and useful way to think about complications fol-
lowing breast augmentation is to divide them into those
that are related to the surgical procedure itself, and those
that are related to the implant or to the biologic integra-
tion of the implant by the body. Surgical complications
that are noted within the first 4 weeks following surgery
are referred to as acute complications. These include
hematomas, seromas, infections, and problems with
wound healing, including wound separation with implant
exposure. A rare complication is that of superficial venous
thrombosis in the superficial veins on the inferior breast,
known as Mondor’s disease. More commonly seen is a
thrombosis of the small superficial veins in the axillary
region in patients who undergo breast augmentation
using a transaxillary approach (Fig. 3-24).
Complications seen within the next 2 months are
termed as subacute complications, and these mainly refer
to implant malposition. Most often this consists mainly of
excessive fullness in the upper pole of the breast that is
noted in the early postoperative period. This is not
uncommon when the implant has been placed in the sub-
pectoral position. In my experience this is the most
FIGURE 3-24. The typical appearance of superficial throm-
bophlebitis in the axillary veins. Note cord below skin.

Chapter 3
Revising the Unsatisfactory Breast Augmentation
85
commonly noted abnormality early on after breast
augmentation. From my perspective, in these situations
there is little concern that the implant will descend to the
appropriate level if the implant was noted to be in the
appropriate position at the completion of the operation.
Most often the implant will settle into a lower position as
the pectoralis major muscle stretches out during the first
4 months following surgery. However, if significant mal-
position of the implant in a medial, lateral, or inferior
location is present at 3 months following surgery, it can
lead to a permanent breast asymmetry or deformities that
very well might represent an indication for revisional sur-
gery on the breast(s) later in the postoperative course.
Additional surgical or technique-related complications
are decreased nipple sensibility; breast asymmetry;
implant edge palpability; and the presence of ripples,
ridges, or folds that can be seen through the skin. The lat-
ter three conditions are noted if the dimensions of pocket
dissection is inappropriate—either too large or too small.
Late complications following breast augmentation are
seen much more frequently. Most of these are implant
related. These would most notably include implant palpa-
bility,18 ridges or rippling at the edges of the implant,40
implant malposition either inferior or superior in location
and that result in either inadequate or excessive superior
pole fullness respectively, lateral implant subluxation,
medial implant malposition, or symmastia if medial
implant malposition is bilateral. Implant malposition is
noted with increased frequency due to the use of increas-
ingly larger saline implants. Contour deformities may
occur long after the placement of the implant and these
can be related to capsular contracture.9
Inherent risks of breast implant placement are the
result of the patient’s biologic incorporation of the
implant or problems related to this process. The most
commonly occurring of these is capsular contrac-
ture.8–10 Also seen are dynamic deformities of the
implant related to contraction of the pectoralis muscles
in patients who have undergone retropectoral position-
ing of their implants (Fig. 3-25), which is a difficult
problem to address. Finally, implant failure marked by
rupture41-45 with gel extrusion if silicone gel has been
used, or deflation if a saline implant has been
employed,14-17,46 is commonly seen following a previous
breast augmentation.
ACUTE COMPLICATIONS
Hematoma Formation
Excessive accumulation of blood in the periprosthetic cap-
sular space is a relatively rare complication following
breast augmentation. It occurs in less than 2% of the cases
as noted by various reports.42 Certainly a significant degree
of dissection is done to create a pocket for the implant in
either the subglandular plane or subpectoral space. As
noted, my approach is to perform almost all of this dissec-
tion gently and precisely with the electrocautery device
under direct vision with a headlight or lighted retractor or
using an endoscope. Meticulous hemostasis is checked for
and procured following the completion of such a dissec-
tion before the implant is placed.
I strongly believe that it is important for all patients to
refrain from the ingestion of aspirin and all products
containing cyclooxygenase inhibitors for at least 1 week
before surgery. I will cancel a breast augmentation proce-
dure if a patient has ingested any medicine containing
aspirin within a week before surgery.
I do not feel that it is necessary to obtain a bleeding
time, prothrombin time, or platelet count before a routine
breast augmentation in a patient without a history of pre-
vious bleeding disorders. I do inquire about bleeding ten-
dencies marked by easy bruising, very heavy menstrual
flows, excessive bleeding after dental work, or explained
bleeding after previous surgery. If any of these conditions
are present and are mentioned in the history, I then
request are bleeding time. If this bleeding time is abnor-
mal, the patient should be informed about this and a con-
sultation with a hematologist initiated to investigate this
situation. Any problems that the patient has had with
episodic hypertension should also be sought and treated
before surgery.
FIGURE 3-25. AP view 3 years after subpectoral augmentation
with smooth-walled saline implants. Distortion of the breast
implant produced by voluntary contracture of the PMM follow-
ing a subpectoral breast augmentation.

Despite careful surgical technique, hematomas occur
in approximately 2% of patients.42,45 The clinical symp-
toms most often include localized discomfort in the
breast. In more pronounced cases (Fig. 3-26) there may be
associated swelling and ecchymosis of the breast.
Treatment of breast hematoma is directly related to the
severity of the process. A patient who complains of pain in
the breast that is increasing, and especially if it is localized
to one side, should be seen as soon as possible to be exam-
ined. After this examination, if it is deemed that the
hematoma is small or of minor severity, i.e., there is no
sign of visible difference between one breast and the other,
and no difference between breast appearance noted
immediately at the completion of surgery in the operating
room and what is now present, then observation with
careful breast support in terms of a dressing or a well-fit-
ting bra is provided. Most of the time this breast immobi-
lization is all that is needed. Such patients can usually
begin displacement exercises within a week to 10 days
after surgery.
On the other hand, if there has been significant accu-
mulation of blood (see Fig. 3-26), it is best to advise the
patient that re-exploration for drainage of the hematoma
is necessary. It is my practice to preoperatively discuss
with each patient the potential need for operative inter-
vention in the acute postoperative period. I specifically tell
patients that if a hematoma occurs they may require addi-
tional surgery. I also tell them that I will provide this serv-
ice to them without an additional professional fee, but in
the hospital environment in which I currently operate,
patients are told that they would be responsible for
charges related to the use of the hospital operating room
and anesthesia services. (I give this information to all of
my cosmetic surgery patients.)
If the diagnosis of significant hematoma is made, the
exploration of the periprosthetic capsular space can be
done through the previous incision, except if it was placed
in the axilla. I find that reopening an axillary incision and
exploring the submuscular space, even using an endo-
scope, is a difficult operation and, in my opinion, it should
not be attempted. Therefore, I tell patients who select a
transaxillary approach that should they develop a
hematoma, another incision on the breast, usually in the
IM location, will be needed to allow the best possible
exploration to evaluate any potential sources of bleeding
and thus I will convert the patient to IM incision for an
inspection of any bleeding.
At the time of reoperative surgery to evaluate a
hematoma, most often no distinct bleeding point is found.
This is true in spite of careful evaluation of the previously
dissected space. Any blood in the space is evacuated, and
careful irrigation of the space is performed with sterile
saline and antibiotic irrigation. When the surgeon is satis-
fied that there is no active bleeding, the implant can be
replaced. Most often I insert a small suction drain, which
is brought out laterally on the chest wall within the bra
line, locating it in the midaxillary line. The surgeon should
inform the patient about potential drain placement before
surgery. These drains [most often a 10-mm Jackson-Pratt
(Cardinal Health, McGaw Park, Ill)] are left in place until
the drainage is less than 30 cc per 24 hours.
Such a case is illustrated by this 18-year-old patient
with a developmental breast asymmetry related to a con-
stricted breast deformity (Fig. 3-27A–C). She requested
bilateral breast augmentation with silicone gel implants.
The approach consisted of an IM incision for the partial
retropectoral placement of different sized implants. We
used a 260-cc smooth normal-profile silicone device on
the left side and a 325-cc smooth low-profile silicone gel
implant on the constricted right side to increase the
apparent base width of the breast. When we contacted the
patient the day following surgery, she reported signifi-
cantly more pain on the right side than on the left and she
was immediately seen in the office. There was no differ-
ence in size at that point and the discomfort on palpation
was not excessive. Her discomfort persisted, and when she
was seen on postoperative day 5 there was obvious
swelling of the right breast and signs of ecchymosis (see
Fig. 3-26). She was advised that surgical re-exploration
was necessary and was returned to the operating room on
postoperative day 8 for an evacuation of a 60-cc
86
Reoperative Plastic Surgery of the Breast
FIGURE 3-26. A hematoma in the right breast following a par-
tial subpectoral breast augmentation seen on postoperative day
6. Note ecchymosis and size difference between the breasts.

Chapter 3
Revising the Unsatisfactory Breast Augmentation
87
FIGURE 3-27. A, Preoperative AP view of a patient with breast hypoplasia superimposed on a
constricted breast deformity producing an asymmetry. B, Lateral view. C, Oblique view. D, Hematoma
right breast noted on post-operative day 6 following partial sub-pectoral breast augmentation requiring
operative re-exploration for drainage.
hematoma. A new implant was placed along with a
Jackson-Pratt drain. The drain was removed within 1
week and she was begun on displacement exercises. At
2 months following the hematoma evacuation surgery, she
demonstrated excellent symmetry between the breasts
(Fig. 3-28A), soft breasts (Fig. 3-28D), and correction of
the constricted breast deformity (Fig. 3-28B,C).
My analysis of the breast implant literature reveals
that a patient who develops a hematoma following a
breast augmentation is at increased risk for later develop-
ing capsular contracture.42–45 For that reason I believe
that it is important to treat significant postoperative
hematomas aggressively by surgical exploration and
drainage.

88
Reoperative Plastic Surgery of the Breast
FIGURE 3-28. A, Postoperative appearance of the breasts on AP view 6 months following surgical
drainage of the hematoma. Note excellent contour and symmetry with no evidence of capsular contrac-
ture (B) and correction of the tuberous breast deformity (C–D). Breast implants are soft and have no
evidence of capsular contracture as demonstrated by patient squeezing the breast.

Chapter 3
Revising the Unsatisfactory Breast Augmentation
89
SEROMA
Some degree of fluid accumulation occurs around all
breast implants after they are placed as part of the reac-
tion of the body to surgical manipulation of the tissues, or
“surgical injury.” This problem is rarely of significance,
however. The study found its incidence to be 1%. I believe
that this fluid accumulation might be increased from
shear stresses between the implant and surrounding tis-
sues. For this reason I have all of my patients refrain from
vigorous activities for at least 6 weeks following breast
augmentation procedures. Additionally, I have them sup-
port their breasts with elastic support for 24 hours a day
during the first month following surgery by wearing a bra.
I have never operated on a breast augmentation patient
for a suspected postoperative seroma.
In my experience the development of seromas has been
more common with the use of textured surface implants.
This is true for both textured silicone gel implants and tex-
tured saline implants. When using a textured device, it is
absolutely essential to precisely dissect the pocket before
placing these implants and, more important, to position
the implant in a very precise manner because a textured
implant will not move from its original position. Seromas
can result in the formation of a biofilm around an implant.
Such a biofilm can lead to the increased possibility of
implant shifting and subsequently to implant malposition.
In addition, the accumulation of seroma fluid may result
in an increased tendency for swelling in the breast, or a
patient’s perceiving and “hearing” a sloshing sound when
moving about. Because there is an increased tendency for
seroma fluid elaboration with the use of textured implants,
I routinely place suction drains when textured implants
are used for breast reconstruction procedures. I have not
adopted this practice when using textured implants for
breast augmentation, but rather I rely on precise pocket
dissection and accurate implant placement.
In all likelihood most seromas are small in volume and
are of little consequence to the overall surgical result.
However, if a seroma causes significant swelling, it may be
difficult to distinguish from a hematoma. I make the diag-
nosis of seroma based on a clinical examination and usu-
ally an ultrasonographic examination of the breast (a
sonogram performed by a radiologist). If there is a signifi-
cant fluid accumulation, I feel that it is best to re-explore
the breast wound in the operating room to evacuate the
seroma and to place the drain. In my opinion this allows
optimal healing between the implant and the surrounding
tissues.
An alternative treatment involves displacing the
implant medially and performing a sterile percutaneous
aspiration of the seroma fluid using an 18-gauge intra-
catheter. This must be done using strict aseptic technique.
The patient must be informed that it is often necessary to
perform such aspirations a number of times before the
process resolves and that each of these aspirations carries
with it a small but definite risk of damage to the implant or
infection.
INFECTION
Infection is a dreaded complication of any procedure in
which a breast implant is placed. Fortunately its occur-
rence is rare. The quoted incidence of infection is between
1% and 4%42 but varies between 1% and 2% in most series
published in the literature.47–49 Infections following breast
augmentation appear either early (most common) or late.
Perioperative infections are defined as those that occur
within 30 days of surgery, whereas late infections may
occur at any time thereafter, often without any apparent
reason or associated infectious event.
If infection occurs following breast augmentation, it is
usually apparent within 7 to 10 days of surgery. Infections
may be either superficial, i.e., involving the area of the
skin incision and superficial subcutaneous tissues only, or
they can present as a deep infection with involvement of
the implant as well. The most common clinical sign of
infection is erythema in the skin which, if there is implant
involvement, is often accompanied by pain with any
movement of the breast implant. With implant involve-
ment there may also be abnormal swelling or pain in the
breast that is present even without moving the implant.
The breast is also most often warm to the touch.
Occasionally there will be drainage from the incision. The
ipsilateral axillary lymph nodes may be enlarged and ten-
der. Rarely are there early systemic manifestations of
infection.
Patients who present with superficial infections at any
early stage (Fig. 3-29A,B) may show a picture of cellulitis
with erythema involving a small or moderate area of the
skin overlying the implant. In this situation there is no
pain on movement of the implant. If such a process is
minimal, then treatment can be initiated on an outpa-
tient basis with a broad-spectrum oral antibiotic or
combination of antibiotics that are effective against
Staphylococcus aureus and Streptococcus spp. I prefer to
use a combination of a cephalosporin [cephalexin (Keflex)
500 mg by mouth (PO) every 6 hours (q6h)] and a semi-
synthetic penicillin (dicloxacillin 500 mg PO q6h) or
Augmentin 825 mg PO 2 times daily (b.i.d.). If the celluli-
tis is more advanced or pronounced in its appearance,
then intravenous antibiotic therapy is begun on either an
outpatient or inpatient basis. I usually use a second-gener-
ation cephalosporin [cefazolin (Ancef) 1 g IV q8h] or a
broader spectrum drug [ampicillin (Unasyn) 3 g IV q6h]. I
will usually see the patient every day to monitor her
progress and to evaluate her clinical response to the spe-
cific antibiotic therapy. A response is indicated by a
decrease in the erythema within 48 hours of initiating the

90
Reoperative Plastic Surgery of the Breast
FIGURE 3-29. A, Cellulitis of right breast following total periprosthetic capsulectomy and implant
exchange for severe capsular contracture. B, Outline of erythema is made on the breast to monitor
resolution.
antibiotic therapy. It has been my experience that, if
caught early, many such infections following breast
implant placement can be successfully treated in this way.
The patient shows resolution of infection at 1 week follow-
ing surgery (Fig. 3-30).
On the other hand, infections involving the breast
implant itself are difficult to treat. To have any chance of
reversing this process they must be treated early and
aggressively. I tell every patient preoperatively that it is
difficult to sterilize an implant that has become infected.
If the infection is diagnosed early, without evidence of
pronounced cellulitis, it may be possible to reverse the
process and salvage the implant. This would be in a case
where there was no infected fluid in the periprosthetic
space around the implant. As previously stated, immediate
treatment with intravenous antibiotics is initiated. If there
is no response within 48 to 72 hours, the patient should be
advised that an imminent return to the operating room for
the purposes of opening the incision and evaluating the
implant is important. At that time, the surgeon can make a
judgment as to the degree of local tissue involvement with
the infection. The implant can be removed from the
periprosthetic capsular space and a Gram stain of any
fluid should be obtained. If there is any evidence of signifi-
cant Periprosthetic capsular fluid in the space that sur-
rounds the implant, especially if this fluid is turbid, or
there is frank purulence around or attached to the implant
(Fig. 3-31), the situation is more ominous. If this Gram
stain shows obvious bacteria or proliferation of white
blood cells, it may be difficult to salvage the implant.
If an attempt to save the implant is elected, the
periprosthetic capsular space is copiously irrigated first
with normal saline and then with an antibiotic irrigation
solution. The wound is then closed and, most often, a suc-
tion drain is then used. In the past suction-irrigation sys-
tems have been used to continuously afford lavage of the
periprosthetic capsular space with an antibiotic solution.
I have not tried this form of therapy.
Most implant infections are caused by gram-positive
organisms, with S. aureus being the most common. In a
study of implant infections following both breast aug-
mentation and breast reconstruction, Courtiss et al.50
found S. aureus in 76% of the augmentation specimens
and in 100% of the breast reconstruction patients.
Additionally, the gram-positive organisms Staphylococcus
epidermis and streptococcus (type A and type B) are most