Reoperative Plastic Surgery of the Breast

92
Reoperative Plastic Surgery of the Breast
Before breast augmentation, part of the informed con-
sent must include the possibility of infection. I routinely
tell patients that should infection occur, it will most likely
be necessary to remove the implant and allow time for res-
olution for the infection and for the attainment of normal
tissue equilibrium. As noted earlier, this time frame is
most often at least 6 months. I tell patients that if implant
removal is necessary, they will be asymmetric if they elect
to maintain implant on the breast that is not involved with
infection. Infections in my practice have been rare (less
than 1%). In the single instance, the patient had a unilat-
eral infection that required implant removal. She asked
me to remove the implant on the contralateral side as well
so as not to be unbalanced during her recovery.
To summarize this overview, as previously indicated,
when addressing an established infection, if the implant
pocket shows signs of fluid accumulation it may be
impossible to save the implant. Attempts to do this are
usually unsuccessful. They are often costly, extremely
inconvenient, and disappointing for the patient. In such
situations I have found it most advisable to remove the
implant, treat the local tissue infection, await resolution
of the process, and allow 4 to 6 months for tissue equilib-
rium to occur. It is at this point that it might be reasonable
to consider reinserting the implant. I believe that waiting
at least 6 months is important to allow the immunologic
processes in the local tissues to eliminate bacteria from
any residual scar tissue.
This clinical scenario is illustrated by the young
woman shown in Figure 3-32 who underwent a bilateral
submuscular silicone gel implant breast augmentation
through an IM incision. She developed an infection
involving the right breast implant that failed to respond
to antibiotic therapy (Fig. 3-32A) and was removed
(Fig. 3-32B). Approximately 1 year later she underwent a
redo of her breast augmentation (Fig. 3-32C). This was
complicated by an inferior implant malposition that
required revision with capsular suture plication of the
lower aspect of her periprosthetic capsule to achieve satis-
factory symmetry of her IM fold levels (Fig. 3-32D).
After allowing suitable time for tissue equilibrium
(most often at least 6 months), it is possible to re-explore
the breast and replace the implant. It may be advisable to
avoid operating through the same incision if at all possible.
I usually select a different incision and very often place the
implant in a different space to minimize any chance of
contamination when replacing a breast implant.
In an attempt to protect the previous breast augmenta-
tion patient against the possibility of infections long after
the original procedure, I administer prophylactic antibi-
otics to such patients when they undergo dental proce-
dures or urologic and proctoscopic instrumentation.55
I do this in a manner similar to that used for patients with
prosthetic heart valves and prosthetic joint replace-
ments.55 I prescribe 2 g of amoxicillin to be taken PO 30
minutes before the procedure, with an additional 500 cc
to be taken 30 minutes after the procedure. For patients
who are penicillin allergic, I prescribe ciprofloxacin 750
cc before and after the procedure on the same dosage
schedule. This practice is not universal among plastic
surgeons.
As outlined in the foregoing paragraphs, infections fol-
lowing breast implant placement are rare. They tend to
occur more often after breast reconstruction than after
breast augmentation. The association between breast
implant infections and implant variables is examined by
Handel et al.,42 who found that infection was more than
twice as common after reconstruction (4.5%) than after
either primary breast augmentation (1.9%) or implant
replacement (1.5%). No associations were detected
between infections and implant filler material, surface
type (smooth versus textured vs. polyurethane), or
implant position (subglandular vs. subpectoral).42
WOUND DEHISCENCE
Wound separation following breast augmentation is an
uncommon problem, with an incidence of 1% to 2%.
When it does occur, it is virtually always seen in the setting
of an IM incision.56 As previously stated, I believe that a
multiple-layer closure of the wound is essential. Such
wound dehiscences are related to inadequate closure of
the wound, or inadequate pocket dissection, which can
cause increased pressure from the implant on the inci-
sion. In addition, a hematoma, seroma, and infection in
the wound can also lead to wound dehiscence.
If the wound separation occurs within the first 2 to 3
days following surgery, the implant may perhaps be sal-
vaged by immediately returning the patient to the operat-
ing room for exploration and reclosure of the wound. If
the separation occurs much later than this (beyond 5
days), I believe that it is almost never possible to salvage
the implant. This is because at this phase of wound heal-
ing the tissues of the wound have a limited ability to hold
sutures. Such a situation is illustrated as follows.
The 39-year-old patient shown in Figure 3-33 presented
to the office self-referred after she noted a problem with
the right IM incision 3 weeks after a breast augmentation
(Fig. 3-33A). There was evidence of exposure of her tex-
tured surface saline implant in the depths of the wound. It
appeared that implant was exerting significant tension on
the wound closure. It was not possible to salvage the
implant, and she elected to have both implants removed
(Fig. 3-33B). A culture of the periprosthetic capsular space
was taken and this returned as negative. We allowed
approximately 8 months to elapse so that the scar would
soften before we returned to the operating room for bilat-
eral implant reinsertion (Fig. 3-33C). This resulted in a
very satisfactory appearance at 1 year following surgery.

Chapter 3
Revising the Unsatisfactory Breast Augmentation
93
In this case I used the patient’s previous incision because
of an asymmetry of the IM folds, which could best be
addressed with the exposure afforded by this IM approach.
This accounted for the additional 2 months of waiting before
proceeding with the surgical revision. However, it is often
advisable to use a different incision to avoid potential prob-
lems with operating through a previous scar. Had there not
been a significant asymmetry of the IM fold, I might have
elected to perform this redo breast augmentation through a
transaxillary or infra-areolar surgical approach.
MONDOR’S DISEASE
Superficial venous thrombosis in the subcutaneous veins
of the breast is a very uncommon entity that occasionally
occurs after any type of breast surgery. Usually this pres-
ents as an area of inflammation with cord formation. It
most commonly occurs at the level of the IM fold. This
superficial thrombophlebitis poses no risk to the patient
in terms of embolization. The patient is instructed to
apply moist heat to the area. This condition is self-limited
FIGURE 3-32. A, Infection of right breast implant following breast augmentation done 7 days earlier.
B, Appearance of patient after removal of both implants. This was done to allow complete healing of the
incision, and 8 months was allowed to elapse before the revision surgery. C, One-year postoperative
appearance following bilateral implant reinsertion. D, The patient is shown 6 months following the
revision surgery to adjust her right IM fold contour.

94
Reoperative Plastic Surgery of the Breast
FIGURE 3-33. A, Patient seen in consultation 3 weeks after undergoing a bilateral glandular breast
augmentation with dehiscence of right IM incision and exposed implant. B, AP view of breasts 4 weeks
following the removal of both implants. C, Appearance 1 year following surgery to reinsert her
implants. This reinsertion was performed 8 months following implant removal.

Chapter 3
Revising the Unsatisfactory Breast Augmentation
95
and usually resolves within 4 to 6 weeks. I most often also
prescribe a nonsteroidal anti-inflammatory drug (NSAID)
such as ibuprofen [600 mg PO four times daily (q.i.d.) for
10 to 14 days].
SUPERFICIAL THROMBOPHLEBITIS OF
THE AXILLARY VEINS
The transaxillary approach is a very commonly employed
route of implant introduction. It involves a dissection
beneath the skin and subcutaneous tissue of the axillary
region. At this point in the dissection the surgeon often
encounters small veins, which are routinely electrocauter-
ized and divided. Cauterization of such veins can cause local
irritation and thrombosis. This may present postoperatively
as an area of discomfort with a palpable cord in the axilla
(see Fig. 3-24). This cord extends from the axilla down the
medial aspect of the arm and often involves the median
basilic vein. It may be uncomfortable for the patient to com-
pletely abduct her shoulder and extend the elbow.
Here, too, the treatment is local and systemic. It
involves the use of moist, warm (not hot) heat and
NSAIDs such as ibuprofen (Motrin). I recommend that
patients take the ibuprofen in the dosage of at least 600
mg t.i.d. for approximately 1 month. This is usually suc-
cessful in reversing the process. Recanalization of these
superficial veins occurs, and generally speaking there is
no permanent sequela.
PROBLEMS RELATED TO INADEQUATE
PREOPERATIVE PLANNING AND
SURGICAL TECHNIQUE
Problems that occur within 3 months of surgery fall into
two categories: inadequate preoperative planning or errors
of surgical technique. Planning errors can result from
unclear communication between the surgeon and patient—
most commonly relating to implant size. Errors in surgical
technique can result in implant malposition and breast
asymmetries. Incomplete or inadequate evaluation of the
patient’s breast anatomy, especially relating to existing
asymmetries57 of volume, breast orientation on the chest
wall, IM fold constriction, and skeletal asymmetries of the
chest wall, are often inadequately corrected or even magni-
fied by the placement of an implant. Both of these types of
errors often result in a suboptimal cosmetic result.
IMPLANT TOO SMALL—PATIENT
DESIRES LARGER SIZE
All patients who undergo breast augmentation seek to
have increased breast fullness. Some patients wish to
reverse changes brought on by pregnancy, weight loss, or
aging, all of which lead to volume loss and very often to
breast ptosis, with the resulting loss of shape. As previ-
ously noted, in my practice the choice of implant size is
based on body habitus, torso dimension, and breast base
width. To appear as close to natural as possible, a
given implant must have the appropriate tissue cover.
Sometimes the thickness of the covering tissues affects the
choice of implant. For example, I believe that it is neces-
sary to select larger implants with greater projection in
obese patients with smaller breasts and thicker subcuta-
neous tissue layer to produce more optimal breast aesthet-
ics following breast augmentation.
It is interesting to note that patients have different ideas
concerning what is most aesthetic, and many are interested
in obtaining a “certain look.” This is illustrated by the fact
that many patients bring in pictures preoperatively indicat-
ing how they want their breasts to appear postoperatively.
Currently there is a plethora of information available on
the Internet with multiple websites (e.g.,
nfo.com) containing information about breast augmenta-
tion and implants.1 In addition, various other sources on
the Internet58 also have pre- and postoperative pictures of
patients who have undergone the procedure. As noted pre-
viously, reviewing and discussing this information with the
patient can be helpful to the surgeon. Input from the
patient regarding desired postoperative size is essential, but
it is the surgeon who must decide if the patient’s desire for
breast appearance following augmentation can or should
be realized and give appropriate advice. As noted earlier,
many patients in the United States seek an increase of one
to two cup sizes with a breast augmentation.1 I believe that
the surgeon should beware of patients who seek a greater
increase than this because their tissues will often not sup-
port an implant of this size, and the reoperation rate in
such patients is high.
Although I never promise a specific bra cup size to a
patient before breast augmentation, it is very important
for me to understand the patient’s desires for postopera-
tive breast size in general terms when using a saline
implant. I generally propose that we use either of two
implant sizes for a given breast augmentation, and the
patient will usually state her preference for going with the
bigger or the smaller size prior to the time of implant
placement. I find that in most instances the patient will
either make a comment about wanting to be natural in
appearance or to be as full as possible, and this is helpful
to me.
Patients who desire an implant size change almost
always wish to be larger. This goal of increased breast size
is usually possible to achieve because the breast tissues
have been expanded by the previously placed implant.
Generally the operation is done using the same access
incision. Most often patients seek superior fullness and a
fuller, more attractive cleavage.

A review of the data in NaBIR,18 which lists the reasons
for reoperation following a previous breast augmentation,
reveals that the two most common reasons given for reop-
eration are “patient desires a larger size” and “patient
preference” (which is also interpreted as “patient desires
larger size”) (Table 3-2). This substantiates my earlier
statement that reoperation to increase the size of the
breast following previous breast augmentation is not at all
uncommon.
The typical scenario of a patient who is dissatisfied
with her size following surgery is illustrated by this 5-feet,
1-inch, 110-lb patient of mine (Fig. 3-34A,B) who under-
went breast augmentation with smooth round implants
filled with 310 cc of saline. These were placed in the par-
tial subpectoral position through an IM incision.
Although they appeared to produce an excellent aesthetic
result (Fig. 3-35A,B), they did not meet the patient’s expec-
tations in terms of breast fullness. She could not adjust to
what she perceived to be an inadequate breast volume,
and her disappointment only increased with time. After 1
year and six office visits, these 310-cc implants were
removed and were replaced with round implants contain-
ing 450 cc of saline. The procedure entailed a medial and
superior capsulotomy (Fig. 3-36A,B) and was carried out
using her previous incision without difficulty. This gave
significant superior fullness and overall breast size, which
the patient had been seeking (Fig. 3-37A,B).
It is important whenever possible when using large
saline implants (>350 cc) for the surgeon to maintain
some of the inferior periprosthetic capsule intact (i.e., to
avoid a complete inferior capsulotomy) to minimize the
potential of subsequent inferior implant malposition. If
this is not possible, then I have found it helpful to place
sutures between the edge of the divided capsule anteriorly
and the deep edge of the capsule posteriorly (Fig. 3-38). To
date I have not interposed a synthetic substrate such as an
allogenic dermal graft59,60 [AlloDerm, LifeCell Corp.,
Branchburg, NJ] for this purpose. However, these grafts
may hold promise in terms of preventing or treating
implant malposition. I predict that such material will
become used more frequently as the increased prevalence
of inferior implant malposition becomes more widely
recognized.
MINIMIZING REOPERATIONS FOR SIZE
CHANGE
Although reoperating to increase the size of a breast
implant is not a common occurrence in my practice
(approximately 1% to 2% of my breast augmentation
patients undergo a change to larger implants), I have had
patients voice the statement “if I had it to do over again I
would have gone larger” to their friends or to my office
personnel. For this reason it is important for each surgeon
to spend a great deal of time listening to the patient to
gain the best possible understanding of the patient’s
desires for postoperative breast size. I rely on my experi-
ence to determine how much fullness will be produced
with a certain size of implant in a specific patient, recall-
ing patients with a similar body type, breast dimensions,
and breast volume with whom I have used a similar
implant. In addition, I make extensive use of implant size
charts provided by the manufacturers. This usually leads
to the appropriate choice of breast implant from a
dimensional perspective. With the range of overfill avail-
able with saline implants (+10% to +30%) and the differ-
ent implant profile types available, there is potential for
increasing the fullness with a certain dimension of
implant of greater than 100 cc depending on the particu-
lar patient.
I have never subscribed to the practice of having a
patient fill a bra with implants preoperatively as a means
of selecting a certain implant size. However, if the surgeon
elects to use this method and subpectoral position is cho-
sen, the choice of implant should be one size larger than
that selected using the process of placing the implant in a
bra. This is to compensate for the compression of the soft
tissues (breast and PMM) on the implant that occurs
in situ.
Although more and more breast imaging programs
are being developed, currently there are no morphing
programs available that can accurately predict the
degree of fullness after breast augmentation produced
by an implant of specific surface and volume dimen-
sions.
REDUCING BREAST SIZE FOLLOWING
BREAST AUGMENTATION
When a change of implant to a smaller size is planned, it is
important for the surgeon to anticipate changes in nipple
position relative to the new breast mound size. This
maneuver often changes the relationship of the breast tis-
sue envelope and also the position of the NAC relative to
the smaller breast implant. Because of this it may be nec-
essary to change the position of the NAC by modifying the
skin envelope with a periareolar, vertical, or inverted
T skin excision in the form of a mastopexy. In addition, it
96
Reoperative Plastic Surgery of the Breast
◗TABLE 3-2 Reasons for Reoperation after Saline
Implant Placement
G Patient requests size change
G Deflation
G Patient preference
G Asymmetry
G Implant malposition
G Capsular contracture
G Ripples, ridges, folds

Chapter 3
Revising the Unsatisfactory Breast Augmentation
97
FIGURE 3-34. Preoperative AP (A) and oblique (B) appearance of patient desiring a breast augmen-
tation from an A cup to a C cup.
FIGURE 3-35. Postoperative AP (A) and oblique (B) appearance following placement of 310-cc
smooth round implants in partial subpectoral position.

98
Reoperative Plastic Surgery of the Breast
FIGURE 3-36. Intraoperative views showing, A, superior-medial and inferior-lateral capsulectomy
and, B, insertion of implant sizer to stretch periprosthetic capsular space.
FIGURE 3-37. Appearance of breasts following implant removal and reinsertion of 450-cc smooth
round implants done in conjunction with a superior capsulectomy in AP view (A) and oblique view (B).

may be necessary to change the position of the implant
relative to the breast tissue with internal suturing of the
capsule (Fig. 3-39) to modify the level of the inferior cap-
sular space, which will alter the appearance of the breast
by changing the relationship of the implant volume to the
overlying breast tissues. Altering the periprosthetic cap-
sule in this way has a very powerful effect on breast shape
and volume. Suffice it to say that altering the soft tissue
envelope is often necessary when decreasing, or downsiz-
ing, the volume of a previously augmented breast.
BREAST ASYMMETRIES
Asymmetries of the breast following augmentation are
not uncommon. It is paramount for the surgeon to care-
fully evaluate the patient preoperatively to detect any pre-
existing asymmetry in the breasts.57 This obviously
includes asymmetries of the IM fold level, nipple areola
height, and nipple areola inclination, as well as asymme-
tries in terms of volume of breast tissue and distribution
of the volume of breast tissue. Not as obvious but never-
theless important are orientation of the breast on the
chest wall and asymmetries of the PMM, sternum (pectus
excavatum), and thoracic skeletal structures. These
asymmetries must be pointed out to the patient preopera-
tively. I very much feel that in many ways a breast aug-
mentation is like exposing the breast to a magnifying
glass. That is to say, that augmentation itself will not cor-
rect many asymmetries, and sometimes it can in fact
magnify them.
It is also important for the surgeon to note the relation-
ship of the patient’s breast to the midline. Many patients
have a wide-set cleavage before surgery, and these patients
will almost always have a wide-set cleavage after surgery.
It is important for the surgeon to inform patients with a
wide-set cleavage that the placement of breast implants
will not provide a tight cleavage postoperatively. An exam-
ple of this is seen in this thin, athletic patient who pre-
sented with breast hypoplasia and a wide cleavage
(Fig. 3-40). These features of her anatomy were carefully
explained preoperatively and she was pleased with the
postoperative outcome of her breast augmentation (Fig. 3-
41), despite that she exhibited a somewhat wide separa-
tion between the breasts.
Nevertheless, it is important to maximize the fullness
in the cleavage in virtually all patients. This is more diffi-
cult when performing a subpectoral breast augmentation.
With this approach it is necessary to divide the inferior-
most sternal origins of the PMM at the xyphoid. The
remainder of the PMM in the parasternal area is attenu-
ated on its deep surface using the electrocautery device set
on the coagulation mode as illustrated in Figure 3-21B.
The amount of attenuation can be gauged by using the
index finger to estimate the tightness of the PMM by exert-
ing a gentle lifting maneuver in a superficial direction
Chapter 3
Revising the Unsatisfactory Breast Augmentation
99
FIGURE 3-38. Suture placement from the superficial fascial
system to the divided edge of the posterior capsule inferiorly.
This maneuver can limit the recurrence of inferior implant
malposition.
FIGURE 3-39. Diagram illustrating modification of peripros-
thetic capsular space by suture capsulorrhaphy to reduce the
volume of the space.

100
Reoperative Plastic Surgery of the Breast
while visually observing the change that this maneuver
produces on the medial contour. It is essential not to
divide the PMM along the sternum because this produces
a contour deformity in the form of a step-off, or paraster-
nal hollow (Fig. 3-42). This deformity is difficult to treat
and every effort should be made to avoid it. The technique
of performing the medial, superior, and inferior dissection
first and adjusting the extent of the lateral dissection last
with a sample sizing implant in place as described earlier
provides the best chance of maximizing medial fullness
and thus breast cleavage postoperatively.
ASYMMETRY OF BREAST VOLUME
As just alluded to, asymmetries of the breast in the
prospective breast augmentation patient are often multi-
dimensional. When multiple characteristics of the breast
and breast architecture are asymmetric, the placement of
a breast implant alone will most often not produce sym-
metry. This should be explained (and re-explained) to the
patient preoperatively. I tell virtually every breast augmen-
tation patient to expect some degree of asymmetry, imply-
ing that it will be subtle in nature. In the reoperative
situation with significant asymmetry I often say, “I cannot
make your right breast look exactly like your left breast.”
MULTIFACTORIAL BREAST
ASYMMETRY—BREAST VOLUME,
ORIENTATION, AND NIPPLE AREOLA
POSITION AND INCLINATION
As previously noted, breasts can be asymmetric in many
respects. This 40-year-old patient demonstrates an asym-
metry of volume, nipple inclination, and orientation of the
breast gland on the chest wall (Fig. 3-43A,B). The right
breast was smaller in volume, and the entire right breast
gland and NAC was inclined in a lateral direction. This gave
the right breast the appearance of having a different lateral
contour than the left breast, with less skin show in its lat-
eral lower pole. The preoperative analysis revealed that the
patient required an implant with a wider base dimension
that would accommodate more volume with slightly more
lateral pocket dissection on the right side than on the left.
An IM incision was used, and the patient had the partial
retropectoral placement of two smooth-walled saline
implants. The implant on the right side had a base width of
12.7 cm and was filled with 440 cc of saline. On the left side
an 11.9-cm base width implant filled with 370 cc of saline
was inserted. This combination produced more lateral
breast show on the right (see Fig. 3-44A,B), with an appar-
ent reorientation of the breast gland to a more forward fac-
ing orientation and good overall symmetry.
FIGURE 3-40. Preoperative appearance of the breasts in a
patient with very wide set cleavage who desired a breast
augmentation.
FIGURE 3-41. Postoperative appearance in same patient who
shows implants that are very far apart, reflecting the basic
anatomic features of her breasts.

Marked improvement is noted on preoperative
oblique view (Fig. 3-45A) and postoperative oblique view
(Fig. 3-45B).
A breast implant can produce the illusion of central-
izing a slight eccentricity of the nipple in some situa-
tions. I find it necessary to study the implant charts (see
Fig. 3-5A,B) to obtain the correct implants from the
standpoint of both dimension and volume. I make the
patient aware of the specific plan as part of the preoper-
ative discussion.
When attempting to produce the illusion of adjusting
nipple position or breast fullness in a specific location the
pocket dissection and implant position are precisely con-
trolled and adjusted accordingly (see Figs. 3-64 and 3-65).
There is a limit to how much of a change can be produced
in the appearance of the breast when adjusting the dimen-
sion, volume, and position of a breast implant. This is due
to the dynamics of implant surgery and the changes pro-
duced in other contours when surgery is directed at
changing a specific area. In this regard there is a parallel
to the dynamics of changing the structure in a nose during
rhinoplasty. The breast surgeon must be mindful of and
anticipate such changes when using an implant to change
the contour and visual illusion of the breast(s).
PREEXISTING BREAST ASYMMETRY
DUE TO COMBINED BREAST VOLUME
AND ROTATIONAL DEFORMITY OF THE
CHEST WALL
In addition to the breasts themselves, the entire area of the
chest must be carefully evaluated in every patient.
Thoracic scoliosis is not uncommon, and if significant
enough the curvature of the spine can result in a rotational
deformity of the chest wall structures such that the skeletal
platform of the ribs and costal cartilages are asymmetric.
This can contribute to an unsatisfactory outcome, requir-
ing reoperation as illustrated in the following case.
This 26-year-old patient who presented for a breast
augmentation was noted to have a pronounced breast
asymmetry, with her right breast being more than a full
cup size smaller than her left (Fig. 3-46A–C). There was a
slight disparity in the nipple heights and size of the areo-
lar complexes and skin envelopes of the breasts. She was
also noted to have more prominent costal cartilages on
the left side due to a scoliosis [Fig. 3-46D]. She underwent
breast augmentation with different sized smooth-walled
saline implants. We used an 11.9-cm base width implant
filled with 340 cc of saline on the left and a 12.3-cm base
width implant filled it with 390 cc of saline on the right
(Fig. 3-47A,B). As the postoperative edema in the breasts
subsided, she was noted to have progressive size discrep-
ancy in the appearance of the breasts (Fig. 3-48A,B), with
the right again noted as smaller than the left. Eight months
following surgery she underwent removal of the right breast
implant and replacement with a 13-cm base width implant
filled with 460 cc of saline (Fig. 3-49A,B). This produced
improved symmetry and gave her the breast appearance
that she was seeking (Fig. 3-50A,B).
As illustrated by the previous case, in these situations of
preexisting breast asymmetry related to skeletal “platform
deformities” (e.g., produced by scoliosis with rotation of
the chest wall structures), it is most often deceptive as to
how much additional implant volume is required to pro-
duce symmetry on the side with the smaller breast. Most
often, substantially more volume is needed than is initially
anticipated. This may be a situation where an adjustable
implant (a Becker or Spectrum–Mentor Corp.) has parti-
cular utility.
INFRAMAMMARY FOLD ASYMMETRIES
As mentioned in Chapter 2, the IM fold is perhaps the key
architectural structure for virtually all plastic surgery pro-
cedures on the breast. This is especially true for breast
implant procedures. The IM fold most often defines the
shape of the lower pole, and it also has a profound effect
on upper breast shape and breast contour following the
placement of a breast implant.
Chapter 3
Revising the Unsatisfactory Breast Augmentation
101
FIGURE 3-42. Step-off deformity in parasternal area of right
breast after release of PMM from the sternum.

FIGURE 3-44. Postoperative appearance at 1 year following augmentation with different dimension
and volume implants with more base width (12.7 cm) and volume (440 cc) on the right than on the left
(11.9 cm and 370 cc). A, AP view; B, lateral view. The different size implants were necessary because of
dimensional (volume and base width) and positional asymmetry of the breasts.
FIGURE 3-43. Preoperative appearance of patient with asymmetry of volume, lateral fullness, and
nipple inclination who desires breast augmentation. A, AP view; B, lateral view.

At this point it is again important to emphasize that the
surgeon must analyze the IM fold for its symmetry, degree
of tightness (see Fig. 2-19) and for any evidence of con-
striction. Asymmetry of the IM folds in not uncommon
(Fig. 3-51) and these must be noted preoperatively so that
appropriate adjustments can be made at surgery. My
understanding of the anatomy of the IM fold and classifi-
cation of the constricted breast deformity have been
reviewed (see Fig. 2-19), but some comments bear rein-
forcement.
The IM fold can be lowered by dissection inferior to it
in the plane deep to the superficial fascia in most cases,
and specifically in those cases where the fold is loose or
just moderately tight. Caution should be exercised when
approaching the patient with an extremely tight fold (see
Fig. 2-19). Dissecting inferior to such a fold with the
implant placed in the partial subpectoral position may not
eradicate the existing fold, and the so-called double bub-
ble deformity (discussed later in this chapter) may occur.
In such cases it may be best to accept the existing IM fold
and select an implant that will be accommodated by the
existing breast soft tissues. Furthermore, it may be aes-
thetically preferable to place the implant in the subglan-
dular position—especially if a silicone gel implant is an
option.
The constricted breast anomaly is manifest by different
degrees of IM fold constriction as illustrated in Figure 2-19.
Subtle (type I) deformities (Fig. 3-52), especially if they are
medially positioned, may persist after implant placement.
The surgeon must recognize this and address this situation
with a biplanar or dual plane dissection, releasing the
fibrous attachments of the fold from the dermis in the area
of constriction. Even with assiduous dissection, remnants
of the partial fold constriction may persist following the
breast augmentation (Fig. 3-53). This possibility should be
pointed out to the patient preoperatively.
A very common problem following breast augmenta-
tion is IM fold asymmetry. It is perhaps more common
with subpectoral than with subglandular breast augmen-
tation. When performing a partial subpectoral breast aug-
mentation, it is important to release the PMM inferiorly to
best achieve a natural and symmetric position of the
implant. This will allow the best possible drape of the
breast tissues over the implant inferiorly, giving the most
natural contour and symmetry to the lower pole of the
breasts. Release of the PMM is straightforward when done
under direct vision. This is most facilitated by the use of
the IM incision. It is most difficult when using the
transaxillary approach for breast augmentation, espe-
cially if the endoscope is not used. However, IM fold asym-
metry can be noted with any of the approaches already
discussed for augmentation.
An example of such asymmetry is illustrated by this 42-
year-old patient who underwent bilateral endoscopic
assisted transaxillary retropectoral pectoral breast aug-
mentation for postpartum involution of the breasts
(Fig. 3-54). She was noted to have an asymmetry of the IM
folds soon after surgery that detracted slightly from the
overall result (Fig. 3-55).
Chapter 3
Revising the Unsatisfactory Breast Augmentation
103
FIGURE 3-45. Comparison of oblique views. A, Preoperative
appearance. B, Postoperative appearance at 1 year.

104
Reoperative Plastic Surgery of the Breast
FIGURE 3-46. Preoperative views of a young patient with a significant breast asymmetry including
volume, nipple areolar position, and skin envelope dimension. The right breast was smaller than the
left. A, AP view. B, Lateral view. C, Oblique view. D, Note prominent costal cartilage–sternal junction
on left side (arrow), which was underappreciated before her breast augmentation.

Chapter 3
Revising the Unsatisfactory Breast Augmentation
105
FIGURE 3-47. Six-month postoperative appearance with mild asymmetry despite using 15% more
volume in right implant. A, AP view. B, Oblique view.
FIGURE 3-48. Fourteen-month postoperative breast asymmetry became accentuated with resolu-
tion of breast tissue edema. A, AP view. B, Oblique view. Patient requests change of right implant to
improve symmetry.

106
Reoperative Plastic Surgery of the Breast
FIGURE 3-49. Plan for changing right implant to larger size with 20% increase in volume. A, AP view.
B, Oblique view with planned inferolateral and radial capsulotomies (outlined by the blue marks).
FIGURE 3-50. Appearance of breasts after reoperative surgery, at which time the volume of the right
implant was increased by 25%.

Chapter 3
Revising the Unsatisfactory Breast Augmentation
107
FIGURE 3-51. Preoperative AP view of patient who is inter-
ested in breast augmentation. Note significant asymmetry in
the levels of the IM fold. Asymmetry documented with tape
measure.
FIGURE 3-52. Partial constriction of the medial aspect of the
IM fold noted before planned breast augmentation.
FIGURE 3-53. The postoperative appearance of breasts on AP
view following biplanar breast augmentation. Note persistence
of IM fold asymmetry due to mild constriction in spite of con-
certed attempt to correct it.
FIGURE 3-54. Preoperative view of patient who underwent a
transaxillary partial retropectoral endoscope-assisted breast
augmentation.

The surgeon must strive to achieve symmetry of the
level of the IM folds at the time of implant placement. At
surgery, it is important to place the patient in the
sitting position at 90 degrees (or as close to 90 degrees as
possible, and I find it necessary to really push the
Anesthesiology Service on getting the operating room
table). This affords the surgeon the best chance to analyze
the position of the implants. Gentle pressure is placed on
the superior aspect of each implant, and they are carefully
assessed for symmetry of the lower pole (Fig. 3-56). If at
the time of this analysis the implant is noted to be too
high, dissection of the inferior tissues can allow incremen-
tal lowering. If the implant is positioned too low, and if the
problem is recognized at surgery, then superior position-
ing of the dissected pocket and new IM fold can be per-
formed with suture reapproximation of the lower thoracic
tissues to the chest wall fascia (Fig. 3-57). This can be
done using either PDS or Prolene sutures (Ethicon, Inc.,
Somerville, NJ). It is important to obtain a good purchase
on both the chest wall fascia (it is not necessary to attempt
suture placement in the periosteum of the ribs) with a
deep stitch and the overlying tissues, including the super-
ficial fascial system (SFS) with the suture placement. I do
not believe that an implant that is low because of exces-
sive inferior pocket dissection it can be superiorly reposi-
tioned by external support of the IM fold with either
Microfoam tape or Reston foam (3M Corp., St. Paul,
Minn.) placed externally and covered with an Ace wrap.
However, such dressing made with a thick foam rubber
sponge can help splint the lower pole (Fig. 8-14E) after it
has been surgically corrected but is unlikely to produce a
correction by itself.
108
Reoperative Plastic Surgery of the Breast
FIGURE 3-56. Maneuver to check symmetry of IM folds.
Patient is sitting at 90 degrees on the operating table. Assistant
places gentle pressure on the upper pole of the implants and sur-
geon analyzes position of the lower poles of the breast implants
and IM fold levels.
FIGURE 3-57. Suture reapproximation of subcutaneous tissues
to the chest wall fascial layer. The purchase of the suture should
be on the superficial fascia of the chest. The suture is not brought
through the skin but is anchored in the superficial Fascia.
FIGURE 3-55. Postoperative view reveals an asymmetry of the
levels of the lower poles of the implants, which at this early time
in the postoperative course is a technical error.

Chapter 3
Revising the Unsatisfactory Breast Augmentation
109
In summary, experienced surgeons realize that asym-
metry following breast augmentation is not uncommon.
Minor postoperative asymmetries are usually accepted by
patients who are pleased with their new breast fullness.
In certain situations created by individual anatomic
variations patients will, in general, tolerate even more sig-
nificant asymmetry following breast augmentation if its
likelihood was pointed out before surgery in an honest
consultation.
IMPLANT MALPOSITION
Breast implant malposition may be the result of inade-
quate planning, an inappropriate choice of implant, tech-
nical error at the time of original implant placement, or
implant displacement at a later time due to factors related
to the implant such as implant size (i.e., weight—espe-
cially if it is a large smooth saline implant). Displacements
may also be due to capsular contracture. Malpositioned
implants may be too high, too low, too lateral, or too
medial. If both implants are too medial, they can encroach
on one another and produce an appearance called sym-
mastia. Some patients exhibit a combination of malposi-
tions that are noted to a greater degree in certain postures
or positions than in others. For example, significant lat-
eral implant malposition (Fig. 3-58) is often more accen-
tuated in the supine position, in which case the entire
medial aspect of the breast is empty or flat in the paraster-
nal area as noted in the patient shown in Figure 3-59, who
was referred for evaluation. Although the incidence of
implant malposition is difficult to discern from published
data (this condition is also referred to as implant displace-
ment or dislocation in some reports), experienced sur-
geons realize that implant malposition is also not
uncommon. An article studying the lifespan of silicone gel
mammary prostheses by Beekman et al.61 refers to
implant dislocation as the second most common reason
for revisional surgery in their series, with a frequency of
23% in 182 breast augmentation and breast reconstruc-
tion patients. The short-term saline implant studies by
McGhan17 (AR95) and Mentor (SPS)16 cited 6% and 8% of
reoperations respectively to treat implant malposition at a
3-year follow-up.
The most common causes of breast implant malposi-
tion are using an inappropriate implant (usually too large),
technical errors during pocket dissection, congenital
deformities (asymmetries and constricted breast anom-
alies), capsular contracture (Fig. 3-60), rupture of a sili-
cone gel implant (Fig. 3-61), and traumatic implant
dislocation or displacement—most commonly seen in the
past after a closed capsulotomy (Fig. 3-62A,B). Closed cap-
sulotomy has been totally abandoned as treatment for cap-
sular contracture and should no longer be done, thereby
eliminating this as a potential etiology of this problem.
Incorrect implant selection generally means using an
implant that is too large for a particular patient. This
situation most often occurs when a large (>400 cc) saline
implant is placed in a small-breasted patient with thin tis-
sues. Most often such a patient’s tissues cannot support
the implant, which will likely migrate in an inferior or lat-
eral direction, especially if it is a smooth-walled saline
implant. Guidelines for implant selection have been exten-
sively reviewed earlier in this chapter.
FIGURE 3-58. Marked lateral malposition of the left breast
implant noted in AP view.
FIGURE 3-59. Lateral malposition significantly accentuated in
the supine position.

110
Reoperative Plastic Surgery of the Breast
FIGURE 3-60. Significant superior malposition of implant
produced by Baker IV capsular contracture, noted in patient’s
right breast.
FIGURE 3-61. Lateral malposition of left breast implant pro-
duced by implant rupture with capsular contracture.
FIGURE 3-62. Superior implant malposition resulting from closed capsulotomy 1 year following
bilateral transaxillary retropectoral breast augmentation with silicone gel implants. A, AP view.
B, Lateral view demonstrates it more dramatically.
Saline implants are typically surrounded by very thin
capsules that do not provide support for the implant,
which migrates inferiorly under the influence of gravity
and produces the clinical appearance of bottoming out.
This scenario is much more common than I have appre-
ciated in the past; I have noted it often when using
smooth-walled saline filled breast implants for breast
augmentation. “Bottoming out” of saline implants is
illustrated in sequential photographs of this patient, who
underwent a partial subpectoral breast augmentation with
340-cc smooth-walled saline implants (Figs. 3-63A–C and
3-64A,B). As stated, this is not uncommon.
To minimize this problem it is important for the sur-
geon to carefully assess the patient’s tissues preopera-
tively, select an appropriately sized implant, and
carefully mark and precisely dissect the implant pocket.
The patient’s tissues are assessed in terms of their thick-
ness, elasticity, and distensibility. I have found that using
a modification of Tebbetts’20 TEPID system has been
helpful.

Chapter 3
Revising the Unsatisfactory Breast Augmentation
111
FIGURE 3-63. A, Two-month postoperative view of breasts fol-
lowing smooth-walled saline 330-cc implant placement.
Appearance at 8 months (B) and 22 months (C) postoperative.
Note significant bottoming out of the implants.
As previously outlined, I believe that the dissected
pocket should fit the implant almost precisely. There is no
evidence that creating excessively large pockets reduces
the incidence of capsular contracture, but plastic sur-
geons have subscribed to creating a large pocket to
encourage implant mobility as a way of promoting soft-
ness of the result. This practice would seem to invite dis-
placement and malposition of the implant. The inferior
extent of the dissection should be carefully planned and
inscribed on the patient’s skin preoperatively. Because
bottoming out is so common, I am now very cautious in
lowering the IM fold of a patient when using a saline
implant with a volume greater than 350 cc unless it is
absolutely necessary. In this case it can be done as care-
fully planned pre-operatively. As mentioned, the lateral
pocket dissection should never go posterior to the midax-
illary line, and this has limited the occurrence of lateral
implant malposition. Tips for avoiding excessive medial
dissection have also been extensively reviewed.
Asymmetries of the IM fold, along with their implications
and their treatment, have been described. Particular
attention should be given to any constriction of the IM

112
Reoperative Plastic Surgery of the Breast
FIGURE 3-64. Oblique views of patient in Figure 3-63 at 2 months A, and 22 months B, postoperative.
fold. In this situation, carefully planned appropriate
releases of fibrous tissue, the breast glandular tissue, and
PMM should be done to address such constrictions at the
time of implant pocket dissection.
Advanced capsular contracture (Baker III and IV)
may produce implant distortion and malposition (see
Fig. 3-60). The most common form seen with silicone
gel–filled implants is superior malposition (see Fig. 3-60),
but lateral malposition (see Fig. 3-61) and other types of
distortion and malposition are also seen. With the exten-
sive use of saline implants in the United States over the
past 10 years, there has been a dramatic decrease in the
incidence of Baker III and Baker IV capsular contractures
and correspondingly less capsular contracture–induced
implant malposition. The tradeoff has been an increased
incidence of inferior implant malposition as noted earlier.
I will now review a practical approach to the etiology
and treatment of the various breast implant malpositions
I have encountered.
IMPLANT TOO HIGH
Excess superior fullness following breast augmentation
can be related to a variety of factors: inadequate inferior
pocket dissection, an implant that is too large (if a sub-
muscular placement has been done or there is inadequate
PMM release), a constriction of the lower pole breast tis-
sues, capsular contracture, and implant rupture if a sili-
cone gel implant has been used.
It is important to realize that following subpectoral
augmentation the implant commonly appears high. If the
implant position was correct on the operating table, at
the end of the procedure it will descend as the PMM
stretches out and the surgical edema in the proximal
PMM resolves. This is especially true if a smooth-walled
saline implant was used. Downward movement in the
pocket can be encouraged by wrapping the upper pole of
the breasts with an elastic wrap (Fig. 3-65B). A slight
excess of superior fullness, if it is symmetric, is often not
objectionable to the patient and in fact is preferable to
suboptimal upper pole fullness. If a textured implant was
used and there is a superior malposition of the implant, it
is very unusual for this implant to obtain mobility and for
correction to occur with external compression or dis-
placement exercises.
Inferior settling of a smooth-walled saline implant fol-
lowing subpectoral breast augmentation is seen in the
patient shown in Figure 3-65. Her implants appear high
on postoperative day 4 (Fig. 3-65A), but by 6 weeks the
breasts show an acceptable upper pole shape (Fig. 3-65C)
and by 3 months the upper pole shape is close to ideal.
Some of these superior implant malposition deformi-
ties will persist, however. When analyzing such a patient,

Chapter 3
Revising the Unsatisfactory Breast Augmentation
113
FIGURE 3-65. A, High-riding right breast implant 3 weeks fol-
lowing subpectoral breast augmentation. B, Elastic wrapping of
the upper pole of the breasts is routine in my practice. Such
wrapping promotes downward movement of a smooth-walled
implant in its dissected pocket. C, Spontaneous descent of
smooth-walled implant seen by 6 weeks postoperative with the
wrapping regimen.

114
Reoperative Plastic Surgery of the Breast
the surgeon must key into both the breast shape and
architecture, especially as it relates to the IM fold, so as to
formulate and propose an appropriate treatment plan to
the patient. The surgeon must carefully analyze the posi-
tions of the IM folds and compare them with the positions
of the IM folds shown in the preoperative photographs. If
the IM fold levels were asymmetric before surgery, then
this must be addressed surgically by releasing the inferior
tissue to lower the higher fold or raise the lower fold to
achieve IM fold symmetry (Fig. 3-66A). The surgeon must
also be aware of nipple position on the breast relative to
the implant and realize that lowering the IM fold or the
lower pole of the implant will raise the apparent nipple
position (Fig. 3-66A). If such a maneuver is necessary,
however, then slight downward repositioning of the NAC
by resecting a crescent of infra-areolar skin is possible.
On the other hand, if the IM fold levels are symmetric
but the implant is too high (i.e., there is an asymmetry of
upper breast fullness) and the implant appears to have
ridden up, it is possible to encourage the downward
movement of the implants by a combination of displace-
ment exercises and wrapping the upper pole (see
Fig. 3-65B). If this is not successful, then the problem
may be due to excessive implant volume or incorrect
implant shape. In such a situation it may be necessary to
reoperate and use either a smaller implant or an implant
with a different shape (i.e., different dimensions). As
noted previously, shaped implants often give the illusion
of more projection and more lower pole volume with
decreased upper pole fullness; therefore they may be a
good option in this situation. It is important to choose an
implant that is not too tall.
If an implant is too high and it has been determined
that surgery is necessary to correct the asymmetry, the
exploration is most often performed through the incision
that was used for the augmentation procedure. The inci-
sion can be either periareolar or IM, which is more com-
mon. Corrections should not be attempted through a
previous transaxillary incision. An inferior capsulotomy is
needed to release the scar tissue around the lower pole of
the implant and reposition it in a more inferior location.
The periprosthetic capsular space is accessed and incre-
mental lowering of the IM fold and implant level is carried
out (see Fig. 3-66B). This is done very slowly and gradually
with the patient placed in the sitting position at 90 degrees
on the operating table. This inferior capsule release allows
descent of the implant. The procedure should be carried
out under direct vision with a headlight or lighted retrac-
tor and is performed most accurately using electrocautery
dissection. If one chooses to reposition an implant that has
been previously placed through a transaxillary approach, it
is best to use an endoscope to facilitate the capsule release
for repositioning this implant.
If a large superior recess of the periprosthetic capsular
space exists, it is sometimes helpful to close down this
recess by performing a superior capsulorrhaphy using
permanent (3-0 Prolene) sutures (Fig. 3-67). If this is
deemed necessary, the surgeon must check the shape of
the breast at the time of suture placement to ensure that
an abnormality of superior breast contour has not been
produced by these sutures.
A final word of caution is in order. Inferior implant
malposition is an increasingly common problem when
saline implants are used. This is especially true when
using large volume (>400 cc) smooth-walled saline
implants. Therefore, caution must be exercised when
completely releasing the inferior capsular tissues when a
smooth-walled saline implant is in place. If a small
amount of correction is needed in the levels of the
implants, I often attempt to leave some portion of the
FIGURE 3-66. A, Lowering the level of the lower pole of an implant will elevate the apparent nipple
position. B, Patient marked for judicious lowering of lower pole of her implants, which is performed by
inferior capsulotomy.

capsule intact to support the weight of a saline implant
and prevent unintended additional inferior malposition.
If complete release of the capsule is necessary, considera-
tion should be given to suture support of the new fold
level as discussed previously. In these cases I believe that
the weight of the breast should be supported with a bra,
and the bra should be worn 24 hours a day for a month
following surgery.
IMPLANT TOO LOW
Implants that are too low produce inadequate fullness and
suboptimal enhancement of the upper poles of the breast,
or they can produce frank breast asymmetries that are
unacceptable from an aesthetic standpoint, which in their
most extreme form present problems with bra fit and
appearance in swimwear. Inadequate upper pole fullness
can be due to implants that are positioned too low, are too
small, or a combination of both.
INADEQUATE UPPER POLE FULLNESS
DUE TO INSUFFICIENT IMPLANT SIZE
AND INFERIOR MALPOSITION
The combination of inadequate size and inferior implant
malposition is a common indicator for reoperation follow-
ing a previous breast augmentation, as illustrated by this
patient (Fig. 3-68A–C), who presented for a bilateral breast
augmentation. The patient had a pre-existing breast asym-
metry, with the left breast smaller in dimension and vol-
ume than the right. She underwent a bilateral partial
subpectoral breast augmentation through an infra-areolar
incision.
The patient was not satisfied with either the postoper-
ative volume or upper pole fullness (Fig. 3-69A–C). The
plan was to replace both implants and raise the IM folds
using the suture capsulorrhaphy technique (see
Fig. 3-39). We used multiple 3-0 Prolene sutures. The
combination of inferior periprosthetic capsular reefing
and exchanging her implants for larger saline implants
(420 cc right, 460 cc left) produced the desired change in
her breast appearance (Fig. 3-70A–C).
IMPLANT TOO LOW—FRANK INFERIOR
MALPOSITION
If the previously placed implant is positioned too low, it is
a more difficult situation. Again, surgical reoperation is
needed to correct the problem. The incision is opened,
along with the periprosthetic capsule. In general the origi-
nal incision is used, unless it was placed in the axilla. In
this case the patient is informed that an IM incision will
provide optimal exposure to achieve correction of the
implant malposition (Fig. 3-71A).
Preoperatively, the surgeon must make an estimate of
how much the fold needs to be raised. This estimation is
obtained by manually pressing on the skin overlying the
lower aspect of the implant. Simultaneously the implant is
elevated and the skin is pressed against the underlying
chest wall (Fig. 3-71B). Circular marks are placed on the
skin at the intended sites of internal suture placement
(Fig. 3-71C). Surgical elevation of the fold is then carried
out under direct vision. I find that it is very helpful to illu-
minate the operative field with either a lighted retractor or
a headlight. The three options are to perform an inferior
capsulorrhaphy using permanent (3-0 Prolene) sutures
(see Fig. 3-39); a double capsular flap repair (Fig. 3-73),
approximating the edges of two concentric ellipses of the
periprosthetic capsular tissue also using permanent (3-0
Prolene) sutures; or a resection of a strip of capsular tis-
sue and approximate raw edge to raw edge of capsular
tissue as illustrated in Figure 6-38H,I. This technique
may have an advantage when a large volume saline
implant (>400 cc) is used, especially if it has a smooth
surface. With this approach the durability of the repair is
related to both the strength of the sutures and the colla-
gen deposition, which is the body’s natural healing
medium.
I find it most important to remove the implant while
performing such corrections. Again, it is necessary to
Chapter 3
Revising the Unsatisfactory Breast Augmentation
115
FIGURE 3-67. Suture capsulorrhaphy closure of the upper
periprosthetic capsular space to close down this aspect of the
space.

FIGURE 3-68. A, Preoperative AP view of patient desiring
breast augmentation to C cup. B, Lateral view. C, Oblique view.

Chapter 3
Revising the Unsatisfactory Breast Augmentation
117
FIGURE 3-69. A, Postoperative AP view seen 8 months follow-
ing placement of 360-cc saline implant on left and 330-cc saline
implant on right in partial retropectoral position through the
infra-areolar incision. B, Lateral view. C, Oblique view.

118
Reoperative Plastic Surgery of the Breast
FIGURE 3-70. A, Postoperative appearance 6 months on AP
view following revision of her breast augmentation with suture
capsulorrhaphy of the inferior capsular recess and placement of
420-cc implant on right and 460-cc implant on left. B, Lateral
view. C, Oblique view.

Chapter 3
Revising the Unsatisfactory Breast Augmentation
119
FIGURE 3-71. A, Inferior malposition of left breast 260-cc saline implant following unilateral subpec-
toral breast augmentation. B, Preoperative digital compression techniques for estimating position of
internal suture placement. C, The circles inscribed on the skin denote position of internal suture place-
ment in the capsular tissue. D, Intraoperative view (different patient) demonstrating the appearance of
the 3-0 Proline sutures in the capsular tissue (see Fig. 3-72 for the outcome of treatment).

incrementally elevate the fold and to check the correc-
tions after they have been made. I usually do this by plac-
ing only about four sutures along the course of the
planned correction. Following correction, the patient is
placed in the sitting position at 90 degrees on the operat-
ing table with one suture in the capsule and a staple clo-
sure of the skin. At this point the adequacy of correction
can be checked. If the correction is what I want to
achieve, I then place additional permanent sutures along
the line of elevation of the periprosthetic capsular tissue.
Very often the tissues are thin. It is imperative that one
not dimple the skin when placing these sutures in the
capsular tissue. Following correction, the patient is
placed in the sitting position at 90 degrees on the operat-
ing table with one suture in the capsule and a staple clo-
sure of the skin. At this point the adequacy of correction
can be checked and final adjustments can be made as
necessary.
Once adequate correction has been achieved, the
wound is closed in customary fashion with a careful
water-tight closure of the capsule. For this layer I prefer to
use a coated polyglycolic acid suture, and 3-0 PDS or
Maxon (Sherwood-Davis & Geck, St. Louis, Mo) is a good
choice. This suture is strong and it slides through the tis-
sues rather than sawing through them. This closure of the
periprosthetic capsule is followed by closure of the deep
dermis; wound closure is completed by an intracuticular
suture approximation of the skin. If there is any concern
about oozing from the capsular tissue surface or possible
seroma fluid accumulation, a suction drain is placed. I
prefer to use a 10-mm Jackson-Pratt drain. The drain is
left in place until the drainage from it falls below 30 cc per
24 hours.
I believe that it is necessary to support the correction of
the IM fold achieved at surgery with external application
of a foam dressing or tape. My preference is to use a thick
piece of foam rubber, which is cut to conform to the cur-
vature and length of the IM fold (see Fig. 8-14). This foam
is placed within the circumferential dressing that is
applied at the end of the surgical procedure. The patient is
then encouraged to continue external support of the fold
correction for at least a month following surgery by wear-
ing a bra to hold it in place. I have been successful in
achieving a permanent elevation of the implant and IM
fold in most cases using this approach.
This young woman with a breast asymmetry (see Fig.
3-71A) underwent unilateral left submuscular breast aug-
mentation with a 260-cc smooth-walled saline implant.
Following this procedure the left breast was larger than
the right and the implant appeared too high (see Fig. 3-
71A). Over the next 4 months she exhibited progressive
settling of her implant, which resulted in frank inferior
malposition of the lower pole. This problem eventually
required correction. The recreation of an appropriate IM
fold level was simulated with digital compression on the
skin (see Fig. 3-71B). This guided the placement of a dou-
ble row of 3-0 Prolene sutures to reposition the lower
level of the periprosthetic capsular space. Conversion to a
120-cc implant produced acceptable symmetry, which
was noted at a 9-month follow-up visit (Fig. 3-72).
MARKED INFERIOR IMPLANT
MALPOSITION
The correction of significant implant malpositions
almost always involves two maneuvers. The first is to
close down the periprosthetic capsular space that results
from the abnormal position of the implant. Most of the
time a second maneuver entails performing a capsulo-
tomy so that the implant may extend into a more appro-
priate position to produce the desired contour.
Additionally, changing the size, surface texture, or filling
substance of the implant may be part of the preoperative
plan.
Inferior implant malposition can be very dramatic at
times. In general this is seen in conjunction with the
placement of extremely large implants, usually with
smooth surface textures. Correction can be achieved by
closing down the inferior extension of the periprosthetic
capsular space (PPCS) and performing a superior capsu-
lotomy, while extending the superior pocket dissection to
accommodate the upper pole of the elevated implant. I
find that resection of a horizontally oriented elliptical seg-
ment of the capsule in the inferior recess of the PPCS and
suturing fresh raw edge of capsule to raw edge of capsule
to be the preferred technique in my hands (see Fig. 6-38,
H, I). In extreme cases it is possible to perform two ellipti-
cal excisions, one on top of the other, to achieve a correc-
tion with sufficient strength to maintain the repair. Such a
case is illustrated next.
I saw a 35-year-old patient 13 months after she had
undergone a bilateral subglandular breast augmentation
with 475-cc smooth-walled saline implants placed
through a periareolar approach (Fig. 3-74A–C). She was
noted to have an extremely prolonged inferior-areola-to-
IM-fold distance and virtually no upper pole fullness.
She requested correction and wanted a 700-cc implant
placed. I advised her that placing an implant with such a
volume was ill advised because her tissues could not
support it.
After three consultations we formulated a plan
whereby we would remove her implant and carry out a
pocket reassignment to a partial subpectoral position.
We performed a capsulectomy and sutured the posterior
aspect of the breast parenchyma to the anterior surface
of the PMM with multiple 3-0 chromic sutures (Fig. 3-75)
using an atraumatic needle to prevent potential prolapse
of the implant back into the subglandular space. We then
excised two ellipses of peri-prosthetic capsular (PPC)
120
Reoperative Plastic Surgery of the Breast

Chapter 3
Revising the Unsatisfactory Breast Augmentation
121
FIGURE 3-72. A, AP view showing correction of IM fold level after internal suturing of capsule. B,
Side-by-side comparison of preoperative malposition and correction.
tissue on the anterior surface of the inferior recess of the
capsule and sutured them to corresponding excised
areas of the posterior aspect of the inferior capsular
recess with 3-0 Prolene sutures using interrupted suture
technique. The moderate-profile saline implant was
replaced with a high-profile smooth-surfaced silicone gel
device with a volume of 550 cc. The correction of the
right side was carried out first, and the elevation of the
IM fold is noted in Figure 3-76. We asked her to wear a
bra to support her breasts for 6 weeks and to avoid stren-
uous activities and any displacement of the implants.
She is seen in Figure 3-77 6 months following the correc-
tion with a much improved aesthetic appearance of the
breasts (Fig. 3-77A–C).
IMPLANT TOO LATERAL
In addition to discrepancies of inferior pocket dissection
producing the problems just described, there can also be

122
Reoperative Plastic Surgery of the Breast
FIGURE 3-73. Double capsular flap technique for modifying periprosthetic capsular space. This tech-
nique combines suture strength and scar tissue repair to modify the space. It involves tracing an ellipse
within an ellipse on the periprosthetic capsular tissue. Both edges of the inner ellipse are elevated off
the deep tissue but stop well in front of the log axis of the ellipse. These edges are then sewn together.
The edges of the outer ellipses are then incised and sewn together. The result is a double suture line
repair that maximizes the suture-holding capacity of the tissue, which may be thin as in the case of the
medial periprosthetic capsule.
excessive lateral displacement of the implant, which also
is most often related to imprecise pocket dissection. This
situation is difficult to correct without surgical interven-
tion because in many natural postures (such as sleeping
in the supine position), an implant will naturally fall lat-
erally under the influence of gravity (see Fig. 3-62B). For
this reason such a malposition usually requires surgical
intervention, with the procedure being directed at closing
down the lateral recesses of the excessively large
periprosthetic capsular space. A concomitant medial cap-
sulotomy may be needed if the medial movement of the
implant is limited on physical examination.
I believe that lateral implant malposition is most often
a technical error due to dissection beyond the midaxillary
line at the time of implant placement. Therefore, this
complication is usually avoidable and relates to the
method of implant pocket dissection at the time of the
original breast augmentation. As mentioned, I believe
that the medial dissection should be performed first in all
cases, with the lateral dissection initially done conserva-

tively based on the preoperative markings. The final lat-
eral dissection is done with the sample sizing implant or
the implant that has been selected in place, again with the
patient sitting up. The dissection should not go posterior
to the midaxillary line, which is marked preoperatively in
every patient who is to undergo breast augmentation.
In my opinion preoperative marking is important for
achieving consistent results with breast augmentation. To
minimize lateral implant malposition I mark the lateral
extent of dissection with the patient in the sitting position
by noting the midaxillary line (Fig. 3-78). This position is
located by drawing a vertical line midway between the lat-
eral edge of the PMM [Fig. 3-78 (single arrow)] and the
anterior edge of the latissimus dorsi muscle [Fig. 3-78
(double arrow)]. The surgeon should make a conscious
effort not to dissect posterior to this line.
This problem of lateral implant malposition can also
result from the use of an excessively large implant (espe-
cially if smooth saline implant is used), trauma to the
implant, implant rupture, and capsular contracture.
At times lateral malposition of the implant is seen
despite careful lateral dissection to establish the pocket.
Correction of this problem requires surgical interven-
tion. It is important for the surgeon to be aware of the
type and size of the implant used at the previous surgery.
As part of the corrective procedure it may be necessary to
use a smaller implant, especially when a significant
downsizing of the lateral capsular recess is planned. If
part of the patient’s problem includes folds that are visi-
ble through the skin, it may be necessary to change an
implant from a textured-surface to a smooth-surface
implant. A substitution of a smooth-walled silicone gel
Chapter 3
Revising the Unsatisfactory Breast Augmentation
123
FIGURE 3-74. Marked inferior implant malposition seen 1 year following a subglandular breast aug-
mentation with 475-cc smooth-walled saline implants seen on AP (A), lateral (B), and oblique
(C) views.

implant for a saline-filled implant in these situations is
ideal. These considerations should be reviewed with the
patient preoperatively. It is also important to convey to
the patient that a perfect correction may not be possible,
and also that after an apparent good early result a slight
resubluxation of the implant is possible due to recurrent
stretching of the lateral periprosthetic capsule and lat-
eral chest wall tissues.
This procedure is done by opening the patient’s previ-
ous incision unless the original incision was in the axilla.
In this case an IM incision is used because it provides the
best exposure for the correction. It is important to explain
to the patient the need for this additional incision on the
breast. The periprosthetic capsule is opened and the
implant is removed. The lateral periprosthetic capsular
space is closed down by means of a double capsular flap
repair. This is done by tacking the anterolateral capsular
tissues to the posterolateral capsule as illustrated in
Figure 3-72. I sew raw edge of the divided capsule to raw
edge of capsule with interrupted suture technique using a
permanent monofilament suture (3-0 Prolene). The
implant is then replaced and an assessment of improve-
ment is noted. If further plication of the capsule is needed,
this is carried out with the placement of additional
sutures. Additional rows of sutures confer additional
strength to the repair. A smaller implant may be placed at
this point if the original implant is too large in its dimen-
sion. If a release of the medial periprosthetic capsular tis-
sues is required (it very often is), I perform this before
replacing the implant. The implant is then replaced and
the wound is closed. I place a suction drain [10-mm
Jackson-Pratt or BLAKE (Ethicon, Inc., Somerville, NJ)],
which is removed when the output from the drain is less
than 30 cc per 24 hours. I also splint the correction with a
thick piece of foam rubber applied to the skin of the lat-
eral IM fold and lateral breast area. I instruct the patient
to sleep on her back and to strictly limit any lateral dis-
placement exercises. I ask the patient to refrain from
heavy exercise for at least 6 weeks after surgery and also
to wear a bra to support the implant during this initial
phase of healing.
Correction of such a postaugmentation deformity is
illustrated by this 42-year-old patient who presented with
a marked lateral displacement of her right breast implant
and a mild displacement of her left breast implant. She
had undergone a bilateral transaxillary retropectoral
breast augmentation 3 years earlier with 350-cc smooth-
walled saline implants. Her breasts were soft and she was
satisfied with the volume, but she was always bothered by
the abnormal position of her right breast implant (Fig.
3-79A–C). Preoperative examination revealed that the
right implant was located relatively far from the paraster-
nal area, and it could not be moved to within 3 cm of the
lateral sternal border with medially directed external
pressure (Fig. 3-80A). Therefore a lateral closure of the
periprosthetic capsular space was planned, along with a
medial and inferior medial capsulotomy (Fig. 3-80B). The
entire plan is schematically outlined in Figure 3-81. A
124
Reoperative Plastic Surgery of the Breast
FIGURE 3-75. Suture closure of the subglandular space fol-
lowing implant removal. This is done to prevent accidental pro-
lapse of the implant back into this space after pocket
reassignment to the subpectoral position.
FIGURE 3-76. Appearance on the operating table after the cor-
rection of the right breast done by segmental horizontal resec-
tion of the inferior capsule and suture repair of the anterior raw
edge of capsule to the corresponding posterior edge with perma-
nent 3-0 Prolene sutures. Note differences in the lower level of
the breasts. Six-month follow-up appearance after this treat-
ment is shown in Figure 3-77.

Chapter 3
Revising the Unsatisfactory Breast Augmentation
125
FIGURE 3-77. A–C, Patient shown 6 months following reoper-
ative procedure with a dramatic improvement in breast shape
and excellent upper pole fullness and a well-defined IM fold
bilaterally.

126
Reoperative Plastic Surgery of the Breast
strip resection of lateral capsule and suture approxima-
tion, along with an additional suture capsulorrhaphy,
effectively closed down the lateral recess of the PPCS. The
medial capsulotomies provided a better and more sym-
metric definition of the cleavage. We replaced her
implants with implants of the same dimension and added
20 cc of volume for a total of 350 cc. The patient is shown
in Figure 3-82 5 months following surgery with an excel-
lent correction of her malposition and improved overall
breast aesthetics (Fig. 3-82A–C).
MEDIAL MALPOSITION
If the implant is positioned too far medially, the cleavage
between the breasts can become very tight and undesir-
able. The most pronounced form of this malposition,
symmastia, is when both implant pockets are too medial.
The best way to manage the problem of symmastia is to
try to avoid it. If the surgeon carefully dissects the pock-
ets as described earlier, i.e., taking care to stay at least 1.5
cm from the midline during the dissection on each side,
the potential for creating this deformity should be mini-
mized.
Despite careful pocket dissection by the surgeon, the
problem is occasionally noted following breast augmenta-
tion. It is most often due to unilateral implant malposition,
but it may be bilateral and present as symmastia. When
surgery is needed to correct this problem, there are three
options: pocket reassignment of the implant, suture cap-
sulorrhaphy, or capsular flap repair.
Perhaps the most consistently successful way of
approaching this problem is to perform an implant pocket
conversion. This allows creation of a new implant pocket,
i.e., moving a previous submuscular implant to the sub-
glandular space, or converting a subglandular implant to a
subpectoral position. In the former case it is not necessary
to perform a periprosthetic capsulectomy or to surgically
close-off the submuscular space. It is important to care-
fully dissect the submammary space and maintain at least
1.5 cm from the midline intact and undissected as empha-
sized earlier (see Fig. 3-19).
When performing a subglandular to subpectoral space
conversion, it is important to perform the appropriate
amount of medial submuscular dissection, again staying
1.5 cm from the midline, and it is also necessary to surgi-
cally close-down the subglandular space with multiple
sutures (see Fig. 3-82). These can be either 3-0 PDS or 3-0
chromic sutures, and they should be placed after implant
removal and before dissection of the submuscular plane.
It is necessary to do this to prevent the implant from slip-
ping back into the subglandular position. This is espe-
cially important if a smooth-walled implant is used.
The other treatment options are to close off the abnor-
mally positioned periprosthetic capsular space using
multiple (at least two) rows of permanent sutures (3-0
Prolene; see Fig. 3-39). Because the tissue in this medial
parasternal area is so thin, it is often difficult to achieve
good suture purchase on the anterior tissues without cre-
ating dimpling in the overlying skin. Similarly, it is virtu-
ally impossible to achieve a good suture purchase on the
deep capsular tissues of the medial chest wall. When the
tissues are thin medially and the thickness of the breast
tissue is minimal, it is necessary to maintain the implant
in the submuscular position. It has been my experience
that even well-done suture repairs in this area generally
do not hold up. For this reason I have found that the dou-
ble capsular flap technique (see Fig. 3-73), which is a two-
layered repair of capsular tissue technique, is most
helpful for correcting the problem of medial implant mal-
position. It achieves the most secure apposition of the
capsular tissues by providing the best “suture” holding
tissue elements for the repair. It also allows primary
apposition of fresh periprosthetic capsular tissue sur-
faces. This increases collagen deposition and probably
the long-term strength of the repair. It also has the least
chance of producing dimpling deformities of the skin.
The extra tissue used increases both the surgeon’s and the
patient’s confidence in the repair. In most situations the
FIGURE 3-78. Marking of the midaxillary line preoperatively
in an augmentation patient to limit possibility of lateral implant
subluxation. The area lateral to the midaxillary line should not
be dissected.

Chapter 3
Revising the Unsatisfactory Breast Augmentation
127
FIGURE 3-79. Lateral implant malposition noted in patient 3
years following a transaxillary retropectoral breast augmenta-
tion with smooth-walled saline implants. This is present bilater-
ally but worse on the right side. A, Note wide cleavage and
laterally situated right breast implant. This is markedly accentu-
ated with shoulders abducted (B) and in the supine position (C).
FIGURE 3-80. A, The malpositioned right breast implant cannot be placed in the correct position rel-
ative to the parasternal area by digital compression on the lateral breast skin. B, This means a medial
capsulotomy as outlined on the skin will be needed as part of the correction.

128
Reoperative Plastic Surgery of the Breast
repair is combined with a lateral capsulectomy to permit
slight lateral flow of the implant (Fig. 3-83).
A large suction drain (10 mm Jackson-Pratt) is usually
placed through a laterally positioned small stab incision,
and it is removed when noted to drain less than 30 cc per
24 hours. Nonstick topical foam is placed over the sternal
area inside a circumferential dressing to help maintain
appropriate position during the early postoperative
period. The patient is asked to wear a bra to support the
implants for the first month following surgery and to
refrain from vigorous activity (e.g., heavy lifting, strain-
ing, and bouncing activities) during that period.
Occasionally the plastic surgeon treating implant mal-
position encounters patients who have had several unsuc-
cessful attempts at operative repair of their implant
malposition. This is not uncommon in the case of medial
implant malpositions. In such situations the best strategy
may be to remove the implants and perform a total
periprosthetic capsulectomy with drain placement,
allowing 6 to 12 months for complete tissue healing
before redoing the augmentation. This is a big decision
for the patient, and a detailed preoperative discussion
must take place so that the surgeon can explain to the
patient the need for and shortcomings of this strategy,
including the surgeon’s inability to completely correct the
problem. Medial implant malposition and its correction
is outlined in Chapter 6, Fig. 6-41A–F. A similar approach
is used if the surgeon encounters a postaugmentation
patient.
The simplest and most reliable method of treating
medial implant malposition is that of using a “pocket re-
assignment.” The implant is removed from the excessively
medial pocket and placed into a new or different “virgin”
pocket in either the subglandular or subpectoral position,
which has been dissected with careful attention not to
make it too medial. When the implant is removed from
the subglandular space, this pocket is sutured closed with
interruped 3-0 chromic sutures (Fig. 3-84).
A case illustrating the correction of medial implant
malposition performed with the double capsular flap
technique to close down the excessive medial recess of the
PPCS, coupled with a lateral capsulotomy to achieve dra-
matically improved breast aesthetics, is demonstrated in
Chapter 6, Fig. 6-41A–F. This is also the approach that I
advocate for treating the problem following a previous
breast augmentation.
THE DOUBLE BUBBLE DEFORMITY
A type of inferior implant malposition known as the dou-
ble bubble results when the implant comes to lie below a
tight previous IM fold that persists as a crease above the
new lower level of the implant. It is seen only when the
submuscular position is used and usually results from
attempting to place an implant that is too large for the
anatomic confines of the existing breast.
The IM fold is formed by vertically oriented fibrous
connective tissue condensations extending from the der-
mis superficially to the superficial fascia deeply. Some of
these fibers may extend to the muscle fascia, but the
majority insert into the superficial fascial system (SFS). It
is important to note that embryologically the breast devel-
ops within the superficial and deep layers of the superfi-
cial fascia. Therefore the lower pole of the breast and IM
fold has this relationship to the SFS.
As discussed in Chapter 2, IM folds in different patients
exhibit different degrees of tightness, from none to a pic-
ture of high-fold definition and significant tightness. This
“double bubble” deformity is seen only in patients with
extremely defined or very tight folds.
The inferior level of the breast and IM fold can be
lowered during breast augmentation by extending the
submuscular dissection inferior to the IM fold in patients
with no discernable fold, loose fold, or a moderately tight
fold. In patients with extremely tight folds it is often best
to accept the existing fold and select an implant that will
best fit the anatomic features and dimensions of the
breast. A shaped textured implant or high-profile implant
often gives the illusion of more volume and projection for
a given base width of the breast and is useful in these
patients.
TREATING THE DOUBLE BUBBLE
When evaluating a patient with an established double
bubble, the choices are to attempt eradication or efface-
ment of the IM fold or to backtrack and accept the previ-
ous fold by changing the implant and the periprosthetic
capsular space. The former approach involves meticulous
dissection aimed at releasing and detaching the insertion
of connective tissue fibers at multiple levels of the subcu-
taneous adipose layer, essentially, from the dermis to the
SFS. The dissection is best done with scissors and must be
thorough. In addition, it may be advisable to mold the tis-
sues internally with the implant or even a tissue expander
(more often an option in breast reconstruction patients). I
have found that although some improvement results from
this approach, very often some remnant of the IM fold
persists, and this indentation is often objectionable to the
patient.
More commonly I recommend re-establishing the
lower pole of the implant at the previous IM fold level.
This most often entails an internal suture capsulorrhaphy
and a change of dimension and volume of the implant.
The overall effect is most often a downsizing of breast vol-
ume, which provides the restoration of a more natural
lower breast pole contour. Such a case is illustrated in the
next section.

FIGURE 3-81. The plan for closing down the lateral capsular recess (here by resection of a strip of cap-
sule and suture repair [upper right figure]) and inferior-medial capsulotomy is seen in cross-section.
RIPPLES, RIDGES, FOLDS, AND
IMPLANT EDGE PALPABILITY
Since the FDA’s 1992 directive3 to plastic surgeons work-
ing in the United States to exclusively use saline implants
in patients seeking primary breast augmentation, the
postoperative problems of ripples, ridges, folds, and
implant edge palpability have been more commonly
noted. The etiology of ripples, ridges, and folds (also
known as skin wrinkling) and of implant palpability are
multifactorial. They are related to implant fill volume
(underfilled implants), implant surface characteristics
(more common with a textured implant surface), implant
filler substance (incidence is inversely proportional to
increasing viscosity of the filler substance), and thickness
of the covering tissue envelope (more common with
implants in the subglandular position). In addition, I
believe that there is often implant–pocket disproportion,
or a disproportion between the periprosthetic capsular
space volume and the implant dimension. Although the
problems of ripples, ridges, folds, and implant palpability
are far more commonly noted after the placement of a
saline-filled implant, they can also be seen following sili-
cone gel–filled implant placement. See Table 3-3.
Experience with saline implants obtained over the past
11 years has provided plastic surgeons with a better under-
standing of these problems and has given us a better
insight into how to decrease their frequency.
THEORIES ON THE ETIOLOGY OF THE
PROBLEM
The presence of ripples, ridges, and folds that show
through the skin is the primary aesthetic drawback of
saline implants. It results from folds in the implant shell,
which are a function of the fill volume in the implant and
◗TABLE 3-3 Etiology of Ripples and Folds Following
Breast Implantation Multifactorial
G Underfilled implant
G Implant surface characteristics—traction rippling (textured,
smooth)
G Filler substance (saline, silicone gel)
G Thickness and quality of covering tissue envelope
G Implant–pocket disproportion

130
Reoperative Plastic Surgery of the Breast
FIGURE 3-82. A, Four-month postoperative view following correction of implant malposition noted
on AP view. B, Shoulder abduction view. C, Marked lateral subluxation of implants noted preoperatively
in the supine position. D, View with patient in supine position. Note marked improved when compared
to preoperative appearance in Figure 3-79A–C.

Chapter 3
Revising the Unsatisfactory Breast Augmentation
131
FIGURE 3-83. Schematic outline for correction of medial implant malposition. This includes closure
of medial capsular recess with double capsular flap technique (Fig. 3-73) and lateral capsulotomy.
FIGURE 3-84. A-B, When implant is removed from the subglandular space, the pocket is sutured
closed with interruped 3-0 chromic sutures. This strategy can also be used to treat ripples or folds in the
breast.

132
Reoperative Plastic Surgery of the Breast
the viscosity of the filler substance. They are seen more
commonly when a textured-surface implant is used. A tex-
tured-surface implant, whether it is silicone or saline
filled, can produce traction rippling due to the manner in
which the textured surface is incorporated into the sur-
rounding tissue. The problem is distinctly less common
with silicone gel–filled implants; however, there was a par-
ticular problem with the Dow Corning MSI implant (Dow
Corning Corp., Midland, Mich.), which had a textured sur-
face and was thought to be slightly underfilled in terms of
its gel volume.
I have come to believe that another etiology is that of
capsule–implant disproportion when the capsule that
the implant resides in is substantially larger than the
implant inside the space. This situation is commonly
noted when a smooth-walled saline implant, which gen-
erates a much thinner and flimsy capsule, experiences
gravitational settling, allowing the upper part of the
capsular space to loosely drape over the edge of the
implant.
Implant palpability refers to the ability of the patient,
or the patient’s significant other, to feel the implant. This
is an unnatural and undesirable tactile sensation, and it
usually involves the edge of the implant. It is more
common than ripples, ridges, and folds, but not as objec-
tionable. It is mostly related to inadequate soft tissue
padding, position of placement (it is seen far more com-
monly following breast reconstruction or after subglandu-
lar placement of a breast implant during augmentation),
and surface texture characteristics of the implant (it is
decidedly more common when textured-surface implants
are used). Patients who are thin (Fig. 3-85A,B) are very
likely to feel their implants in the inferolateral aspect of
the breast [Fig. 3-86A,B (arrows)]. I inform such patients
about this preoperatively.
FREQUENCY OF THE PROBLEM
The commonality of postoperative ripples, ridges, folds,
and implant edge palpability following saline implant
placement has been studied by Young et al.63 They com-
bine the ripples, ridges, and folds problem under the
heading of “skin wrinkling” and have devised a scale of I
to III for grading each of these problems (I = none, II =
mild, III = significant).
In the study by Young et al.,63 rippling of the skin over
an implant was noted significantly more often with the
use of textured implants than with the use of saline
implants. In terms of implant palpability, here too there
was a greater incidence of the more advanced forms of
implant wrinkling (levels II and III) after the placement
of textured implants—especially if they were placed in the
subglandular position. In fact, the incidence of undesir-
able implant wrinkling and palpability with textured
implant use was so much higher when placed in the subg-
landular position that the authors63 recommend against
placing them in the subglandular space—especially in
thin patients.
MINIMIZING SKIN WRINKLING
Because the optimal fill volume for some saline implants
may not be precisely known, it is essential that the plas-
tic surgeon never underfill a saline implant. I usually fill
the implant to between 10% and 30% greater than the
suggested fill volume. It may be helpful surgeons to hold
a filled saline implant in their hand in the upright posi-
tion (using the “Tebbetts tilt”),64 observing the shape and
inspecting the edges for rippling as the implant is filled
to, and beyond, the maximum suggested fill volume for
the particular implant. High-profile round saline
implants may in fact show a tendency for less folding
than regular-profile implants as they are filled beyond
the maximum suggested implant fill volume depicted on
the box or in the package insert. However, the surgeon
must be aware that a saline implant will become progres-
sively firmer as its volume increases. Technically, over-
filling beyond 10% may void the warranty, but up to this
point the manufacturers have been lenient with this
transgression.
Additional maneuvers to limit the incidence of rippling
with saline implant breast augmentation predominantly
involve maximizing tissue padding in each patient. I do
this by using the subpectoral position almost exclusively
for breast augmentation, as previously noted. This is true
unless the patient has pre-existing B cup or greater breast
tissue volume—an unusual situation in my breast aug-
mentation practice. The use of the subpectoral position
for augmentation is especially true with a thin PMM and
subcutaneous tissue layer on or adjacent to the breast.
I find these patients to be particularly tough candidates
for breast augmentation, and I routinely tell them preop-
eratively that they will feel their implants postoperatively
in the lower outer aspect of their augmented breast (see
Fig. 3-86A,B).
I almost exclusively use smooth-walled saline implants
for primary breast augmentation—mainly to limit ripples,
ridges, and folds, as well as to minimize the occurrence of
implant palpability.
SURGICAL TREATMENT OF RIPPLES,
RIDGES, AND FOLDS
The treatment of ripples, ridges, and folds usually involves
changing the implant surface characteristics from a tex-
tured implant to a smooth-surface implant. In addition
reassigning a previous subglandular implant to the sub-

Chapter 3
Revising the Unsatisfactory Breast Augmentation
133
FIGURE 3-85. A–B, Extremely thin patient who requests an augmentation mammoplasty with saline
implants. Such a physical habitus places these patients at great risk for implant edge palpability and for
the visual appearance of ripple or folds.
FIGURE 3-86. The patient in Figure 3-86 is shown 1 year postoperative following a partial retropec-
toral breast augmentation with smooth-walled saline implants with a volume of 330 cc. A, AP view. B,
Lateral view reveals implant palpability laterally (arrows), which are present but do not bother patient
because she was informed about them preoperatively.

pectoral space is helpful in that it increases the thickness
of the padding tissue (see Fig. 3-84A,B). Finally, I believe
that decreasing the volumetric dimensions of the peripros-
thetic capsular space by suture tightening the capsule, in
addition to using a slightly larger-sized implant, may be of
real benefit in certain patients. These are the individuals in
whom capsule–implant disproportion is an issue. This
problem is almost exclusively seen with saline-filled breast
implants.
Problems with ridges, ripples, and folds can be dra-
matic, as noted in the patient in Figure 3-87, who
has underfilled saline implants in the subglandular
position after three previous augmentation procedures.
Treatment entails improving the quality of the tissue
padding overlying the implant and often changing the
implant itself. There may be an emerging role for syn-
thetic tissue substitutes in this area. Dowden60 has
reported on the use of AlloDerm to increase the thickness
of the soft tissue between the implant and the skin to treat
folds in patients who have previously undergone breast
augmentation. In another similar publication Baxter59
outlines the use of AlloDerm acellular dermal grafts as an
inlay graft to the superior and inferior aspect of the
periprosthetic capsule to improve rippling following a
saline implant breast reconstruction. The series is small,
but the results are encouraging.
Although I have had little experience with synthetic tis-
sue substrates such as allogenic dermal grafts,59,60 their
use may hold promise in the treatment of ripples, ridges,
and folds, and I suspect that they will have more wide-
spread use following implant breast surgery in the future.
The case just illustrated shows a pronounced fold prob-
lem. The vast majority of cases that I have encountered
have folds that are far less pronounced, however. Such a
case with more subtle folds is seen in the patient shown in
Figure 3-89, who presented with symmastia and visible rip-
ples in the superior medial aspect of her breasts following a
subglandular breast augmentation with textured round
saline implants (Fig. 3-88A,B). This combination of prob-
lems was addressed by the repositioning of smooth-walled
implants into the subpectoral position (see Fig. 3-84). The
PMM provides an increased tissue layer to limit fold visibil-
ity in this location, and the medial (parasternal) origin of
the muscle is an anatomic barrier that limits the problem of
symmastia—providing that the PMM is not released from
the sternum. Postoperatively there is more space between
the breasts (albeit with a good cleavage), and the superior
medial folds are gone (Fig. 3-89A,B).
CAPSULAR CONTRACTURE
Capsular contracture has always been the most common
inherent risk or adverse side effect of breast augmenta-
tion. It is often referred to as a complication, but in fact I
believe it is an inherent risk of every breast implantation
procedure. In most series it maintains a frequency of up to
30%24,66 when silicone gel implants are placed in the sub-
glandular position and 15% to 20%24,25 when breast
augmentation14,15 is performed with saline-filled breast
implants in the same location. It is an exaggerated form of
the collagen fiber deposition, which occurs as part of the
foreign body reaction that occurs in all patients when a
breast implant is placed.67 Advanced forms of this process
produce an unnatural feeling of firmness in the breast,
distortion, and even discomfort68 (Baker IV) (Fig. 3-90).
The etiology of capsular contracture remains unknown.
The two most commonly held hypotheses as to its etiology
are hypertrophic scar formation69,70 and subclinical infec-
tion.71,72 The latter is felt to be due most often to contami-
nation of the periprosthetic capsular space with
Staphylococcus epidermidis—an organism commonly cul-
tured from the periprosthetic capsule of encapsulated
breast implants. The major difficulty with the hyper-
trophic scarring hypothesis is that it does not explain the
commonly observed unilateral occurrence of the process.
In addition, there is no consistent correlation between
capsule thickness and firmness of the implant. The pri-
mary difficulty with the subclinical infection hypothesis is
that many patients with advanced capsular contracture
have negative cultures of the intracapsular space.
134
Reoperative Plastic Surgery of the Breast
FIGURE 3-87. Significant ripples and folds seen in this
patient who has had several breast augmentation procedures.
She has underfilled, textured saline implants in the subglandu-
lar space.

The severity of the capsular contracture process noted
clinically is classified into four types: none, mild, moder-
ate, and severe. The most commonly used system for grad-
ing the severity of the process is that proposed by James
Baker68 (Table 3-4). The most commonly seen variety is
the mild type (Baker II), which is often not offensive to the
patient because some element of breast firmness (similar
to what many patients may have had at the time of
puberty) may be desirable. It is the more severe types of
capsular contracture (Baker III and IV) that are most
bothersome to the patient because these tend to produce
distortion of the implant and result in asymmetry. The
most severe may also produce pain (Fig. 3-90).
Chapter 3
Revising the Unsatisfactory Breast Augmentation
135
FIGURE 3-88. Patient presenting with symmastia and upper pole rippling in the medial aspect of the
breast following previous subglandular augmentation with a textured round saline implant. A, AP view.
B, Oblique view.
FIGURE 3-89. Successful revision was accomplished by placing smooth-walled implants into subpec-
toral position. A, Two-year postoperative AP view. B, Two-year postoperative oblique view.

136
Reoperative Plastic Surgery of the Breast
To date there is no known way to eliminate the occur-
rence of capsular contracture, but certain maneuvers
seem to decrease its frequency and minimize its presence.
The extensive literature on the occurrence of capsular
contracture seems to consistently record a decreased inci-
dence with the submuscular placement of the breast
implant. The exact reason for this reduction when
implants are positioned beneath the PMM is unknown,
but it is likely that muscle contraction produces a con-
stant message that may maximize pliability of the capsule
and act to keep the implant as soft as possible. I personally
believe that positioning of the implant beneath the PMM
may make it more difficult to appreciate capsular contrac-
ture, especially in those patients who have a significant
amount of their own breast tissue.
There is a school of thought that proposes that main-
taining both maximal pocket distensibility and dimension
along with implant mobility by means of displacement
exercises contributes to implant (and breast) softness. I
subscribe to this hypothesis29,30 and instruct my patients to
begin implant displacement (see Fig. 3-23A–C) as soon as
possible—usually by the third postoperative day.
The incidence of capsular contracture has been reduced
with the more widespread use of saline implants.14,15 This
observation has been borne out in numerous reports, and
certainly I can attest to its validity in my own patients.
There may be an advantage to using a textured-surface
implant, especially when the implant is positioned in the
subglandular space. There does not seem to be a benefit
from textured-surface implants when these devices are
placed in the submuscular position, however.
EARLY CAPSULAR CONTRACTURE
The early occurrence of capsular contracture is of particu-
lar concern to both the patient and the surgeon. Using the
early intervention of diligent displacement exercises and
vitamin E in large doses may be beneficial. I prescribe a
dose of 1,000 IU per day for 6 weeks. I believe that in addi-
tion to this pharmacologic intervention, having patients
sleep in the prone position and perform frequent displace-
ment exercises has been helpful in many patients.
The beneficial effect of intensified vigorous implant
displacement exercises and vitamin E therapy was real-
ized in this patient who exhibited a Baker III contracture
of the left breast implant 1 month after a partial retropec-
toral augmentation with a smooth-walled saline implant
(Fig. 3-91A,B). This was despite displacement exercises
done only once a day. She was begun on vitamin E 1,000
IU b.i.d. and instructed to vigorously move her implants
and gently squeeze them with the superior displacement
maneuver (Fig. 3-92). This regimen of treatment was suc-
cessful in restoring a Baker I status to the left breast
within 4 weeks (Fig. 3-93). I do not have controlled study
evidence that this is a consistently predictable effect, but it
has been helpful in many of my patients.
Most recently there have been reports that the asthma
medication alclometasone dipropionate (Aclovate) may
decrease the incidence of capsular contracture or reverse
the process in some patients. I do not believe that this
drug, with significant medical side effects (e.g., hepatotox-
icity), should be prescribed for off-label use.
Most of the time when a breast implant exhibits signifi-
cant contracture, it will be seen by 1 year postoperative.
After that time it is relatively uncommon for a patient to
manifest advancement of the capsular contracture
process. However, there are certain conditions and events
that may lead to a late onset of increased breast firmness.
Events that may produce an accelerated delayed contrac-
ture include trauma to the breast with delayed hematoma
or seroma and intercurrent infection.65
ESTABLISHED CAPSULAR
CONTRACTURE
Once contracture has been established, it is difficult to
treat. There has been some enthusiasm for high doses of
vitamin E therapy; however, the beneficial effects of this
FIGURE 3-90. AP view of patient who exhibits a Baker IV cap-
sular contracture of a left breast implant following previous sub-
glandular augment with silicone gel implant.
◗TABLE 3-4 Classification of capsular concentration
Baker I
The breast is soft and there is no evidence of capsular
contracture
Baker II
The implant can be easily palpated by the surgeon and
the patient
Baker III
There is evidence of a capsular contracture that is firm
and gives the breast a round appearance
Baker IV
The breast is hard, distorted, and may be painful or cold

FIGURE 3-91. A, Preoperative view of patient during breast augmentation. B, One month postopera-
tive AP view showing Baker III capsular contracture of left breast with asymmetry.
FIGURE 3-92. Vigorous superior displacement exercises
carried out.

138
Reoperative Plastic Surgery of the Breast
FIGURE 3-93. Pretreatment and posttreatment appearance of breasts on AP view showing resolution
of the capsular contracture 4 weeks after institution of vigorous displacement exercises done t.i.d.
therapy remain unproven. In my opinion, capsular con-
tracture that presents with implant deformity and breast
asymmetry, or symptoms that may include tightness, cold-
ness, or frank discomfort, is an indication for surgery. The
surgical approach must be carefully tailored to the indi-
vidual patient and, more important, the patient must be
advised that no guarantee for increased softness can be
made. The rate of recurrence of capsular contracture after
surgery is high.
My approach to capsular contracture has been to care-
fully evaluate the patient preoperatively, advise the patient
as just stated, then look at each case with the idea of
“changing something. “In my experience, the operation is
best performed under general anesthesia. It usually
involves reopening the incision made for placement of the
previous breast implant, then identifying the peripros-
thetic capsule. Although some of my colleagues have
touted the benefits of capsulotomy or multiple capsulo-
tomies (Fig. 3-94) with the immediate institution of dis-
placement exercises, in my experience the rate of
recurrence of firmness when only this is done has been
high. Therefore I routinely perform a capsulectomy
(Fig. 3-95), being especially careful to remove as much of the
capsular tissue as possible, especially on the anterior surface
of the capsule. The exceptions to this are patients who have a
thin covering envelope. Most commonly this is either a
patient with very limited breast tissue who has undergone
subglandular breast augmentation, or a patient who has had
a previous subcutaneous mastectomy. In these situations,
performing an anterior capsulectomy may impair the circu-
lation to the overlying tissue and create problems with heal-
ing that may lead to skin loss and tissue atrophy.
I have had success in performing total capsulectomy
surgery to treat advanced capsular contraction, as noted
in the case of a young patient who had undergone a bilat-
eral silicone gel subglandular breast augmentation 11
years before her consultation with me. Over the preceding
18 months she had experienced progressive firmness and
distortion of her left breast (see Fig. 3-90). She recalled
that this breast was firm immediately following surgery,
and she had undergone two attempts of closed capsulo-
tomy. This seemed to make her breast somewhat softer
but it was never as soft as the opposite right breast. She
presented with a Baker IV capsular contracture of the left

breast implant, which produced a visible distortion of the
left breast with superior implant malposition on that side
[see Figs. 4-25 and 4-28 (left side of composite)]. The breast
implant was intermittently painful and was uncomfort-
able to touch. She underwent a total periprosthetic cap-
sulectomy (Fig. 3-96) and implant removal, followed by
the reinsertion a new smooth-walled silicone gel breast
implant. This was successful in restoring softness and a
more symmetric appearance to the breasts (see Figs. 4-26
to 4-29).
If the capsule is to be left in place in a thin patient with
a previous subglandular implant, it is often possible to
change the position of the indwelling implant. Most com-
monly, this is a change from the subglandular to the sub-
pectoral position. When placing an implant in this
location, it is important to release the origin of the PMM
inferiorly as already discussed. This will result in the
upper 70% of the implant being submuscular, with the
lower 30% lying under the lower pole of the breast tissue
or in the subcutaneous tissue, resulting in dual plane
repositioning. If such a repositioning is carried out, it is
not necessary to perform a capsulectomy. The exception
to this would be a situation with significant silicone gel
bleed or intracapsular rupture where, if silicone gel is
contained within the periprosthetic capsule, this gel
could lead to the formation of a siliconoma or problems
with chronic seroma accumulation because of silicone in
the scar tissue space, which will not undergo any type of
reabsorption.
Relocation to the submuscular space is helpful in
achieving the interposition of additional soft tissue
between the implant and skin surface. This dual plane
repositioning alone can confer to an implant more of a
feeling of softness (Fig. 3-97). Spear et al.73 have
Chapter 3
Revising the Unsatisfactory Breast Augmentation
139
FIGURE 3-94. Multiple capsulotomy technique that can be
used in reoperation to treat established capsular contracture.
FIGURE 3-95. The technique of total or subtotal capsulectomy
is an alternative to multiple capsulotomies.
FIGURE 3-96. The technique of total periprosthetic capsulec-
tomy done through an IM incision illustrated a contracted cap-
sule around the implant.
FIGURE 3-97. Schematic outline of the dual plane technique
used to treat capsular contracture. It involves increasing the vol-
umetric dimension of the periprosthetic capsular space and
increasing the distensibility of the tissue in the breast as a means
of help promoting a softer texture to the breast.

recently touted this dual plane approach as a reliable
method of surgically treating established capsular con-
tracture. The technique for the procedure includes
recreating the PPCS so that it is partially subpectoral
and subglandular. The procedure acts to increase the
internal volume of the PPCS and to increase the disten-
sibility of the tissues so as to increase the softness of the
implant. My early experience with this technique has
been positive.
Removing the periprosthetic capsular tissue is impor-
tant. It can be carried out through either an IM approach
(which in my experience is ideal) or a periareolar
approach. I find it impossible and therefore ill advised to
attempt a capsulectomy through an axillary incision, even
with the use of an endoscope.
The procedure entails the use of a headlight that will
facilitate direct visualization of the entire dissection. The
dissection is carried out with a combination of electro-
cautery dissection and blunt fingertips (see Chapter 4).
The latter maneuver is possible if the plane between the
breast tissue and the periprosthetic capsule can be easily
developed. Should this plane not lend itself to easy dissec-
tion, the electrocautery is indicated to maintain hemosta-
sis and to facilitate the dissection.
When the implant is already below the PMM, I believe
that at a minimum it is important to remove the anterior
capsule. If the posterior capsule lends itself to safe exci-
sion (and most often this has been the case in my experi-
ence), then it too should be excised. This will provide a
neo-virginal space in which to place the new implant.
Although I have previously stated that in most cases plac-
ing a textured implant in the subpectoral position is not
beneficial in the setting of a previous capsular contrac-
ture, it may be wise to change the implant surface texture
as part of the procedure.
If implant replacement into the subglandular space is
planned, then a total capsulectomy will allow placement
of a new implant into a neo-virginal pocket. This can be
helpful in perhaps altering the healing process that has
resulted in a capsular contracture. Meticulous hemosta-
sis should be procured. If I perform a total capsulec-
tomy, I routinely place a suction drain through a short
incision located laterally within the shadow of the
breast.
After the implant has been explanted, the new implant
is put into position. Conversion to a different location is
helpful. Additionally, there is some published evidence
that use of a textured-surface implant may decrease the
rate of capsular contracture. Should a textured implant
be used, it is important for the surgeon to precisely dis-
sect the accepting pocket to the dimensions of the
implant. This will minimize the incidence of implant mal-
position, palpability, and pocket disproportion but
increase the chance that ridges, ripples, and folds will
develop.
In my experience, textured implants do seem to incite
more of a problem with seroma formation. Because of
this I make liberal use of drains and routinely drain
patients after implant exchange surgery when a textured
implant has replaced a smooth implant. The drains are
left in place until they drain less than 30 cc of fluid per 24
hours. This indicates that the elaboration of serous fluid
is at its minimum and the stage has been set for incorpo-
ration of the implant and good tissue to implant inter-
face healing. The drains are routinely removed within
the first week (usually between the third and fifth post-
operative day), but it is not uncommon for a drain to be
left in for more than a week. Obviously the patient must
keep the drain clean and dry. I routinely maintain
patients on oral antibiotics while the drains are in place
[cephalexin (Keflex) 500 mg PO q.i.d.]. I do not have
patients massage their implants unless they are smooth
surfaced.
SUMMARY STATEMENT ON
CAPSULAR CONTRACTURE
Capsular contracture remains the most prevalent undesir-
able side effect of breast implant placement for either
breast augmentation or breast reconstruction. Its etiology
is unknown. Maintaining strict sterile technique using
barrier drapes on the skin and antibiotic irrigation of the
dissected space, along with minimal handling of the
implant, may reduce its incidence.
Established contracture that is bothersome to the
patient can be surgically treated, often with improvement.
The concept of changing some element of the previous
treatment schema is important, and this has been reviewed.
Substantial decreases in capsular contracture rates will
probably require an increased understanding of how to
pharmacologically or chemically manipulate the foreign
body reaction. Such may be possible with an increased
understanding of cytokine interactions and effects on the
biology of wound healing. Alternatively, new directions
regarding implant design and manufacture will likely be
necessary.
IMPLANT FAILURE—RUPTURE OR
DEFLATION
An inherent risk of breast implant placement is implant
failure. This occurs with all types of biologic implantation
devices. The subject of silicone gel implant rupture is
extensively reviewed in the Chapter 4.
Saline implants also fail or exhibit deflation. As of this
writing the deflation rate appears to be 2% per year per
implant.14,15 This seems to be a linear relationship when
the patients are followed for a period of 12 years.
140
Reoperative Plastic Surgery of the Breast