Reoperative Plastic Surgery of the Breast

142
Reoperative Plastic Surgery of the Breast
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Most saline implant deflations result in complete
flattening of the breasts. I advise patients that if saline
implant failure occurs, they should seek correction
(implant replacement) within the first week. This is
because if the problem is ignored and is not treated dur-
ing that time, then the periprosthetic capsule around the
implant contracts. This will require much more exten-
sive surgery, including capsulotomy or even capsulec-
tomy, to restore the dimensions and distensibility of the
PPCS.
Partial implant deflation can also occur with saline
implants. This is far less common. I estimate that it
accounts for 0.5% of such deflations. A patient exhibiting
this problem is illustrated in Figures 3-98 and 3-99. She
presented with folds in her right breast implant and much
less volume on that side 2 years after an initial breast aug-
mentation (Fig. 3-98A,B). At surgery she was found to
have tissue ingrowth into the nipple valve of her implant.
This was removed and replaced with an implant of the
same dimension and volume as that present in the oppo-
site breast, with the restoration of satisfactory symmetry
and the elimination of the folds in the breast contour
(Fig. 3-99A,B).
The message here is that partial deflations with
saline-filled breast implants can occur. In the situation
of saline implant deflation following breast aug-
mentation (or breast reconstruction), a better result
with much less surgery usually is realized with early
(within the first week) rather than late surgical
intervention.

Chapter 3
Revising the Unsatisfactory Breast Augmentation
143
20. Tebbetts JB. A system for breast implant solution based on
patient tissue characteristic and implant-soft tissue dynam-
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21. Bostwick J III. Personal communication.
22. Tebbets JB. Alternatives and trade-offs in breast augmenta-
tion. Clin Plast Surg. 2001;78:485–500.
23. Hidalgo DA. Breast augmentation: choosing the optimal inci-
sion, implant, and pocket plane. Plast Reconstr Surg. May
2000;105(6):2202–2216; discussion 2217–2218.
24. Puckett CL, Croll GH, Reichel CA, et al. A critical look at
capsule contracture in subglandular versus subpectoral
mammary augmentation. Aesthetic Plast Surg. 1987;11(1):
23–28.
25. Vazquez B, Given KS, Houston GC. Breast augmentation: a
review of subglandular and submuscular implantation.
Aesthetic Plast Surg. 1987;11(2):101–105.
26. Handel N, Silverstein MJ, Gamagami P, et al. Factors affect-
ing mammographic visualization of the breast after augmen-
tation mammaplasty. JAMA. October 14, 1992;268(14):
1913–1917.
27. Adams WP Jr., Conner WC, Barton FE Jr., et al. Optimizing
breast pocket irrigation: an in vitro study and clinical impli-
cations. Plast Reconstr Surg. January 2000;105(1):334–338;
discussion 339–343.
28. Lindsey JT. The case against medial pectoral releases: a ret-
rospective review of 315 primary breast augmentation
patients. Ann Plast Surg. March 2004;52(3):253–256; discus-
sion 257.
29. Vinnik CA. Spherical contracture of fibrous capsules around
breast implants. Prevention and treatment. Plast Reconstr
Surg. November 1976;58(5):555–560.
30. Camirand A, Doucet J, Harris J. Breast augmentation:
compression—a very important factor in preventing capsular
contracture. Plast Reconstr Surg. August 1999;104(2):
529–538; discussion 539–541.
31. Weiss NS. Breast cancer mortality in relation to clinical
breast examination and breast self-examination. Breast
J. May–June 2003;9(suppl 2):S86–S89.
32. Smith RA, Saslow D, Sawyer KA, et al. American Cancer
Society guidelines for mammographic screening: update
2003. CA Cancer J Clin. 2003;53:141–169.
33. Eklund GW, Busby RC, Miller SH, et al. Improved imaging of
the augmented breast. AJR Am J Roentgenol. September
1988;151(3):469–473.
34. Miglioretti DL, Rutter CM, Geller BM, et al. Effect of breast
augmentation on the accuracy of mammography and cancer
characteristics. JAMA. January 28, 2004;291(4):442–450.
35. Holmich LR, Mellemkjaer L, Gunnarsdottir KA, et al. Stage
of breast cancer at diagnosis among women with cosmetic
breast implants. Br J Cancer. March 24, 2003;88(6):832–838.
36 Jakub JW, Ebert MD, Cantor A, et al. Breast cancer in
patients with prior augmentation: presentation, stage, and
lymphatic mapping. Plast Reconstr Surg. December
2004;114(7):1737–1742.
37. Baker JL Jr., Bartels RJ, Douglas WM. Closed compression
technique for rupturing a contracted capsule around a breast
implant. Plast Reconstr Surg. August 1976;58(2):137–141.
38. Embrey M, Adams EE, Cunningham B, et al. Factors associ-
ated with breast implant rupture: pilot of a retrospective
analysis. Aesthetic Plast Surg. May 1999;23(3):207–212.
39. Robinson OG Jr., Bradley EL, Wilson DS. Analysis of
explanted silicone implants: a report of 300 patients. Ann
Plast Surg. January 1995;34(1):1–6; discussion 6–7.
40. Collis N, Platt AJ, Batchelor AG. Pectoralis major “trapdoor”
flap for silicone breast implant medial knuckle deformities.
Plast Reconstr Surg. December 2001;108(7):2133–2135; dis-
cussion 2136.
41. Young VL, Watson ME. Breast implant research: where we
have been, where we are, where we need to go. Clin Plast
Surg. July 2001;28(3):451–483, vi.
42. Handel N, Jensen JA, Black Q, et al. The fate of breast
implants: a critical analysis of complications and outcomes.
Plast Reconstr Surg. December 1995;96(7):1521–1533.
43. Holmich LR, Friis S, Fryzek JP, et al. Incidence of silicone
breast implant rupture. Arch Surg. July 2003;138(7):801–806.
44. Rohrich RJ, Adams WP Jr., Beran SJ, et al. An analysis of sili-
cone gel-filled breast implants: diagnosis and failure rates.
Plast Reconstr Surg. December 1998 Dec;102(7):2304–2308;
discussion 2309.
45. Biggs TM, Yarish RS. Augmentation mammaplasty: a com-
parative analysis. Plast Reconstr Surg. March 1990;85(3):
368–372.
46. Lavine DM. Saline inflatable prostheses: 14 years’ experience.
Aesthetic Plast Surg. Fall 1993;17(4):325–330.
47. Mladick RA. “No-touch” submuscular saline breast augmen-
tation technique. Aesthetic Plast Surg. Summer 1993;17(3):
183–192.
48. LeRoy J, Given KS. Wound infection in breast augmentation:
the role of prophylactic perioperative antibiotics. Aesthetic
Plast Surg. Fall 1991;15(4):303–305.
49. Rheingold LM, Yoo RP, Courtiss EH. Experience with 326
inflatable breast implants. Plast Reconstr Surg. January
1994;93(1):118–122.
50. Courtiss EH, Goldwyn RM, Anastasi GW. The fate of breast
implants with infections around them. Plast Reconstr Surg.
June 1979;63(6):812–816.
51. Dougherty SH. Pathobiology of infection in prosthetic
devices. Rev Infect Dis. November–December 1988;10(6):
1102–1117.
52. Brand KG. Infection of mammary prostheses: a survey and
the question of prevention. Ann Plast Surg. April 1993;
30(4):289–295.
53. Clegg HW, Bertagnoll P, Hightower AW, et al. Mammaplasty-
associated mycobacterial infection: a survey of plastic sur-
geons. Plast Reconstr Surg. August 1983;72(2):165–169.
54. Thornton JW, Argenta LC, McClatchey KD, et al. Studies on
the endogenous flora of the human breast. Ann Plast Surg.
January 1988;20(1):39–42.
55. Pittet B, Montandon D, Pittet D. Infection in breast implants.
Lancet Infect Dis. February 2005;5(2):94–106.
56 Fodor L, Ramon Y, Ullmann Y, et al. Fate of exposed breast
implants in augmentation mammoplasty. Ann Plast Surg.
May 2003;50(5):447–449.
57. Rohrich RJ, Hartley W, Brown S. Incidence of breast and
chest wall asymmetry in breast augmentation: a retrospective
analysis of 100 patients. Plast Reconstr Surg. April 1,
2003;111(4):1513–1519; discussion 1520–1523.
58. Sagrillo D Bsn Rn Cpsn, Kunz S Bs Rn Cpsn. Surfing the
Internet for information on breast augmentation. Plast Surg
Nurs. October–December 2004;24(4):158–164.
59. Baxter RA. Intracapsular allogenic dermal grafts for breast
implant-related problems. Plast Reconstr Surg. November
2003;112(6):1692–1696; discussion 1697–1698.
60. Dowden DI. Correction of implant rippling using allograft
dermis. Aesthetic Surg J. 2001;21:81.
61. Beekman WH, Feitz R, Hage JJ, et al. Life span of silicone
gel-filled mammary prostheses. Plast Reconstr Surg.
December 1997;100(7):1723–1726; discussion 1727–1728.
62. Tebbetts JB. A system for breast implant selection based on
patient tissue characteristics and implant-soft tissue dynam-
ics. Plast Reconstr Surg. April 1, 2002;109(4):1396–1409; dis-
cussion 1410–1415.
63. Young VL.
64. Tebbetts JB. Patient acceptance of adequately filled breast
implants using the tilt test. Plast Reconstr Surg. July
2000;106(1):139–147; discussion 148–149.
65. Hipps CJ, Raju R, Straith RE. Influence of some operative
and postoperative factors on capsular contracture around
breast prostheses. Plast Reconstr Surg. March 1978;61(3):
384–389.
66. McKinney P, Tresley G. Long-term comparison of patients
with gel and saline mammary implants. Plast Reconstr Surg.
July 1983;72(1):27–31.
67. Wagner H, Beller FK, Pfautsch M. Electron and light
microscopy examination of capsules around breast implants.
Plast Reconstr Surg. July 1977;60(1):49–55.

144
Reoperative Plastic Surgery of the Breast
68. Baker DE, Schultz SL. The theory of natural capsular con-
tracture around breast implants and how to prevent it.
Aesthetic Plast Surg. 1980;4:357.
69. Smahel J. Histology of the capsules causing constrictive
fibrosis around breast implants. Br J Plast Surg. October
1977;30(4):324–329.
70. Thomsen JL, Christensen L, Nielsen M, et al. Histologic
changes and silicone concentrations in human breast tissue
surrounding silicone breast prostheses. Plast Reconstr Surg.
January 1990;85(1):38–41.
71. Burkhardt BR, Fried M, Schnur PL, et al. Capsules, infection,
and intraluminal antibiotics. Plast Reconstr Surg. July
1981;68(1):43–49.
72. Burkhardt BR, Dempsey PD, Schnur PL, et al. Capsular con-
tracture: a prospective study of the effect of local antibacter-
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73. Spear SL, Carter ME, Ganz JC. The correction of capsular
contracture by conversion to “dual-plane” positioning: tech-
nique and outcomes. Plast Reconstr Surg. August 2003;
112(2):456–466.

A p p e n d i x A
◗
Consent To Surgery And Anesthesia
I, ________________________ authorize Dr. Kenneth C. Shestak and/or such assistants
[Name of Patient]
and other physician(s) as may be designated by him, to perform the following surgical procedure(s), which I understand
to be: Breast augmentation
[Description of Procedure(s)]
The above procedure(s) have been fully explained to me by Dr. Kenneth C. Shestak and I understand the risk of the pro-
cedure to be as follows: Bleeding hematoma, seroma, infection, wound separation, implant exposure, loss of implant if
exposure or infection occurs, capsular contracture (possibly advanced), altered nipple sensation, contour asymmetry,
ripples, ridges or folds in skin, pain, rupture or deflation, allergic reaction to medications, unfavorable scar position or
formation, need for unplanned additional surgery, suboptimal cosmetic result
And the consequences of the procedure(s) to be as follows: ____________________________________________________
1. I acknowledge that I have discussed alternative treatment and options of no treatment with my physician.
2. I understand that during the course of the procedure, unforeseen or unexpected conditions may arise which neces-
sitate additional or different procedures immediately necessary to treat my medical condition and to preserve my
life or health. I request and authorize my physician(s) to perform such procedures which in the physician’s profes-
sional judgment are deemed medically necessary.
3. For the purpose of advancing medical education, I consent to the admittance of observers and discussion of my
procedure with others who may not be directly responsible for my care.
4. I understand that my physician(s) or others under the direction of my physician may choose to record, photograph,
televise or videotape all or any portion of my operation for medical, scientific or educational purposes. I consent to
the recording, photographing, televising and videotaping of the operations or procedures to be performed, includ-
ing appropriate portions of my body, provided my identity is not revealed. I understand and agree that 1) any pho-
tographs, films, videotapes or other audio or visual recordings will be the sole property of Magee-Womens Hospital
and will not become part of my medical record; and 2) Magee-Womens Hospital or any appropriate staff member
may edit, preserve, destroy or release to my physician all or any part of the photographs, films, videotapes or other
audio or visual recordings.

146
C h a p t e r 4
◗Evaluating Implant Integrity and
Explantation Options and Techniques
Over the past decade, many plastic surgeons have seen a
number of patients with concerns about or problems with a
previously placed breast implant. In the early 1990s many
of these consultations were prompted by the adverse pub-
licity1 surrounding breast implants, such as concerns about
safety issues,2 especially with regard to any link between
the presence of silicone gel breast implants and the devel-
opment of connective tissue disease or other diseases.
These patients were extremely anxious and even angry
about presumed health problems with their breast
implants. Two extensive reviews of virtually all the data on
silicone gel implants published in the medical literature3,4
and many other peer-reviewed studies5–8 have now dis-
proved the potential induction of or link between any
known disease process and silicone implants, thus making
it possible now to reassure patients who have had implants
placed for any reason about the safety of these devices.9
Nevertheless, it is imperative that the plastic surgeon
employ a thorough and systematic evaluation of all
patients who have undergone previous breast implanta-
tion if there is a suspected problem with the implant(s).
This analysis is directed at establishing the status of
implant integrity and entails a careful evaluation of the
patient’s breasts from an aesthetic and general breast
health perspective.
DIAGNOSTIC APPROACH
In my practice the approach to the potential explantation
patient entails taking a careful history, noting the chief
complaint and other complaints, and a detailed review of
past breast health history (including all mammograms,
biopsies, and operations) and other medical conditions,
followed by performing a careful physical examination.
Appropriate laboratory and breast imaging studies are
then recommended and additional consultations sought if
indicated. The goal is to make a diagnosis regarding any
implant problem.
The history is very important. It must include details of
the previous operation(s), the type of implant, anatomic
position of the implant, complications of the previous
Diagnostic Approach 146
Physical Examination 147
Imaging Modalities for Breast Implants 149
Indications for Explantation 152
Implant Failure 153
Treatment of Implant Failure 153
Management of the Periprosthetic Capsule 154
Technique of Capsulectomy 158
Summary Statement on Capsulectomy 159
Treatment Options Following Explantation 159
Explantation Alone 159
Explantation with Implant Reinsertion 161
Explantation with Mastopexy Alone 167
Explantation with Augmentation Mastopexy 175
Explantation with Autogenous Tissue
Conversion 177
Autogenous Conversion Following Previous
Breast Augmentation 177
Autogenous Tissue Conversion Following
Suboptimal Implant-Based Breast
Reconstruction 179
References 182

Chapter 4
Evaluating Implant Integrity and Explantation Options and Techniques
147
procedure and any related incidental occurrences such as
trauma to the breast, particularly searching for a history
of closed capsulotomies, etc. A review of previous opera-
tive reports and physician records is the most precise way
of gaining the most accurate knowledge about the previ-
ous surgery(ies). Specific complaints or problems related
to the breasts most often include firmness as the result of
capsular contracture, asymmetry, nipple or skin sensory
changes, breast pain, and changes in implant position or
the development of a mass in the breast or an irregularity
that may be related to the implant edge. The physician
must key into symptoms of pain, especially the occur-
rence of burning pain that may involve the breast, lateral
chest area, or axillary region. This symptom can result
from implant rupture. Previous breast problems are also
important to note. Such problems include any history of
previous breast masses, imaging studies, and all breast
biopsies and pathology reports pertaining to them.
Changes in the patient’s breast examination (noted by
either the patient or the physician) and the new onset of
pain symptoms in the breasts are important to catalogue.
Obviously any family history of breast cancer is also
important to note.
The presence of generalized systemic symptoms must
also be noted. These include any history of myalgias,
arthralgia, fatigue, hair loss, and dryness of mucous mem-
branes, as well as any neurologic complaints. It is impor-
tant to thoroughly review previous diseases, including the
presence of known connective tissue disease, cardiac dis-
ease, respiratory disease, thyroid problems, and other
endocrine diseases, during the initial evaluation.
In my practice most often the typical patient has expe-
rienced no specific breast complaints but is referred for
evaluation after breast imaging studies have suggested the
diagnosis of implant rupture.10–14 Importantly, although
patients experiencing local discomfort in the breast
related to capsular contracture or implant rupture might
be improved by implant removal, it has been my experi-
ence that patients who are experiencing any systemic
complaint(s) are rarely improved by the removal of the
implants. Patients are informed of this before any planned
explantation procedure.
PHYSICAL EXAMINATION
As with all plastic surgery evaluations, the first part of the
examination entails careful inspection. For the patient with
a possible implant problem, this begins with observing the
movement and posture of the patient, as well as her general
appearance. Vital signs are recorded, along with height,
weight, and bra size. Next, the appearance of the breasts is
analyzed for any asymmetry in volume, skin envelope
dimension or quality, nipple areola size or location, and
degree of mammary ptosis. It is important to assess
whether the implant is frankly visible or causing distortion
of the breast (Fig. 4-1), implying an advanced capsular con-
tracture or perhaps rupture. Perhaps most important is
noting the location of previous scars and taking into
account their potential effect on the blood supply of the
nipple areolar complex (NAC). Any asymmetry, distortion
of the breast tissue, and nipple irregularities are also noted.
Next, the relationship of the NAC to the breast mound
and implant is noted. It is also important to note the rela-
tive degree of ptosis and to determine the relationship of
the existing breast tissue to the underlying implant. It is
relatively common for the breast tissue to settle away from
the implant (see Fig. 4-1), especially in patients approach-
ing the fifth decade, or in situations in which the implants
have been in place for more than 15 years. Very often the
breast will exhibit a dependent appearance, especially if
the implants are of the smooth-walled saline variety. In
these cases some form of a mastopexy may need to be
incorporated as part of the surgical plan.
A worksheet with a breast diagram (Fig. 4-2) is com-
pleted detailing the anatomic and tissue features of the
breast, including the base width and the relationship of the
NAC to the inframammary (IM) fold and the suprasternal
notch (SSN), with notations about the breast skin and
parenchyma. The location of all previous breast scars is
FIGURE 4-1. Anteroposterior (AP) view of breasts in 47-year-
old patient who underwent a breast augmentation 12 years
earlier. She displays settling of her breast tissue away from her
implants and a visible abnormality in the right breast that was
due to an implant rupture.

148
Reoperative Plastic Surgery of the Breast
FIGURE 4-2. Breast worksheet for potential explantation patient.

Chapter 4
Evaluating Implant Integrity and Explantation Options and Techniques
149
also recorded on the diagram. In addition, information
about the patient’s past breast history, including details of
the previous surgery(ies), is entered. As mentioned in
Chapter 3, this includes the type, size, and position of the
indwelling implant and notations regarding incisional
approaches along with any information about previous
mastopexies. Sensation of the breast skin and nipple are-
ola area is also noted.
Following this the breast is palpated for any abnormal-
ities in the parenchymal tissue or on the surface of the
implant itself. The patient is asked to contract her pec-
toralis major muscles (PMMs) and in this way whether the
implant is located in the subglandular or submuscular
position is suggested (if such information cannot be
obtained from the previous records). This maneuver gives
the surgeon an insight into the degree of distortion of the
breast with contraction of the PMM. The examiner then
notes the degree of firmness in the implant. The firmness
is graded on a spectrum of none to severe and is recorded
in the form of the widely accepted Baker Classification
Score15 (Table 4-1). The edge of the implant is then care-
fully palpated for, specifically to assess for any evidence of
irregularity, rippling or undulations, firmness, or discrete
masses that might be adjacent to the implant. Next, the
surgeon observes for the presence of any nipple discharge
or nipple irregularity. The skin is carefully observed for
any distortion or mass. The axillary area is carefully evalu-
ated for any sign of palpable abnormality, including
lymph nodes, masses, and previous scars.
IMAGING MODALITIES FOR BREAST
IMPLANTS
I believe that the diagnostic impression of whether the
implant is ruptured or intact is almost never obtained
from physical examination alone. The exception to this is
the case of an easily palpable abnormality in the breast tis-
sue (especially if it is an acute change) related to an
episode of direct trauma to the breast. More often the
diagnosis of implant integrity can only be obtained from
an interpretation of imaging studies of the breast, which
include a combination of mammography,10 breast sonog-
raphy,11,12 and magnetic resonance (MR) scanning.13,14
The mammogram remains the standard way to image
the breast tissue in every woman’s breast,10 regardless of
whether an implant is present.16 It is the only method by
which microcalcifications in the breast can be visualized.
It employs x-rays of the breast in various planes, including
the craniocaudad and mediolateral views (Fig. 4-3A,B).
I instruct patients to follow the mammography schedule
as proscribed by the American Cancer Society.16 I instruct
the patient to have the first mammogram performed at
age 35, the next at age 40, mammograms every other year
until age 50, and yearly studies thereafter.16
The presence of a breast implant limits the amount of
breast tissue that can be imaged to a variable extent due to
the radio-opacity of the implant itself.10 The amount of
breast tissue that is concealed varies from approximately
9% to 49%17 depending on the position of the implant and
whether capsular contracture exists.18 To increase the
amount of tissue that can be imaged, special displacement
views, as described by Eklund10 (Fig. 4-4A,B), are widely
used. With this technique the implant is pushed posteri-
orly toward the chest wall and the breast tissue is dis-
tracted anteriorly to obtain increased visualization of the
breast parenchymal tissue. This must be done gently in a
radiology unit experienced in performing mammography
in patients with implants because implant rupture is a
rare reported complication of mammography.19
The breast tissue that is most concealed is that area
alongside the implant itself11 (Fig. 4-5). To obtain the best
visualization of this area, ultrasound or breast sonogra-
phy has been widely employed. It provides a valuable
adjunct to the mammographic imaging studies.
Sonography relies on transmitted sound waves, which are
directed through the breast and reflected back to a receiv-
ing probe. It has long been used to aid in the diagnosis of
breast pathology because it can provide information as to
whether a palpable or mammographically demonstrated
lesion is cystic or solid (Fig. 4-6).
In a similar way sonography is helpful in imaging a
breast implant because there is differential sound wave
transmission through the breast tissue and breast
implant. Therefore, the sonography examination of the
breast produces an image of the implant that is separate
and distinct from the surrounding breast tissue. The
implant appears as a nearly anechoic structure that is
dark on the sonographic image. In contrast, the breast tis-
sue is hyperechoic (or appears white). This yields a pic-
ture of the implant as sharply distinct and contrasted
from the surrounding breast tissue11,12 (Fig. 4-7).
Sonography of the breast is highly operator depend-
ent.11,12 It yields the most useful information when
performed by a radiologist who has taken a history, per-
sonally examined the patient, and evaluated the mammo-
grams. This allows a careful, focused examination of a
specific area of the breast that may require that the patient
be placed in various positions (Fig. 4-8).
TABLE 4-1 Baker Classification of Capsular
Contracture
Baker I
No evidence of firmness; breast feels as soft as a normal
breast
Baker II
Examiner and patient can feel implant
Baker III
Breast is moderately firm and may exhibit distortion of
contour
Baker IV
Breast is hard, painful, or cold

150
Reoperative Plastic Surgery of the Breast
As previously noted, because of the differential sound
wave transmission characteristics of breast tissue and sili-
cone, in the hands of an experienced operator the tech-
nique of sonography is highly reliable for making the
diagnosis of extracapsular implant rupture. In this situa-
tion, silicone gel has moved beyond the confines of the
periprosthetic fibrous capsule into the breast tissue and
usually lies adjacent to the implant. The ultrasound
appearance of such a condition is that characteristic of a
snowstorm12 (Fig. 4-9). It is different from the sharply
marginated interface between the implant and the
surrounding breast tissue. Our experience reflects that
such a finding is highly predictive (>98%) of extracapsular
rupture that has been confirmed at surgery.11,12,20 We
believe that the presence of this snowstorm appearance
allows the physician to make the diagnosis of extracapsu-
lar breast rupture with confidence, and therefore it allows
him or her to recommend implant removal to the patient.
Intracapsular rupture is more difficult to image with
sonography of the implant. With intracapsular rupture a
tear has occurred in the elastomer shell of the silicone gel
FIGURE 4-3. Standard mammographic views for screening
mammogram. A, Craniocaudal view. B, Mediolateral view.
FIGURE 4-4. A–B, Eklund displacement views illustrating the
increased visualization of the breast tissue (A) over the standard
compression view as the implant is displaced posteriorly.

Chapter 4
Evaluating Implant Integrity and Explantation Options and Techniques
151
implant, but there has been no egress of the silicone gel
outside the periprosthetic capsule surrounding the
implant. Because the gel is confined within the peripros-
thetic capsule (the rupture is contained within the colla-
gen envelope surrounding the implant), it is called an
intracapsular rupture. The prevalence and incidence of
this condition is difficult to establish with certainty
because most often these patients do not have any symp-
toms and there are no changes in the appearance or feel of
the breast. With intracapsular rupture the sonogram may
show an abnormal reflectance of sound waves, referred to
as a stepladder sign12 (Fig. 4-10), which is the result of
FIGURE 4-5. Breast tissue, which is most obscured by the
implant, is alongside and posterior to the implant as seen on
these x-ray films.
FIGURE 4-6. Ultrasound of the breast in patient with a cystic
lesion anterior to the breast implant. This method delineates the
implant and identifies the breast mass as cystic.
FIGURE 4-7. Breast sonogram in patient who has had a previ-
ous augment. Note the different signal characteristics at the
interface of the implant and breast tissue. The implant is hypo-
echoic and marked as “xx.” The skin is marked as “xxxx.”
FIGURE 4-8. The utility of breast sonography is highly opera-
tor dependent. Photograph shows a radiologist carefully per-
forming a breast sonogram to delineate a lesion. The radiologist
has taken a history and examined the patient and is focusing the
examination.

sound reflecting off the surfaces of the elastomer shell
that lies within the aggregate of the gel.
A more sensitive, specific, and accurate way to image a
breast implant, especially with regard to the diagnosis of
intracapsular rupture, is by using magnetic resonance
imaging (MRI).13,14 This modality allows more precise
delineation of the elastomer shell, periprosthetic capsule,
and gel within the implant. In situations where there is a
frank tear of the elastomer membrane, the shell appears to
become intermingled within the central portion of the gel
and appears as a serpentine group of lines, which has been
named the linguini sign13 (Fig. 4-11). It is highly suggestive
of intracapsular rupture. I use MRI as my second modality
for establishing the diagnosis of intracapsular rupture and
will order this study if the sonographic evaluation of the
implant is equivocal or nonconclusive. Our data20 indi-
cate that the sensitivity and specificity of MRI exceed 90%
in the diagnosis of intracapsular rupture, and this is con-
sistent with other findings recorded in the literature.
It is most common to use a number of these studies to
establish a diagnosis of implant integrity or loss of
integrity. I subscribe to the algorithm proposed by Cheung
et al.21 when ordering imaging studies to evaluate a poten-
tial breast implant problem.
Finally, I believe that intracapsular rupture of a silicone
gel implant represents a failure of the implantation device
(and the U.S. Food and Drug Administration [FDA]
defines this as such), and it is my practice to recommend
the removal of such an implant to the patient. However,
at the time of this writing there is no uniformity among
plastic surgeons as to the treatment of this entity. That is
to say, some surgeons will explain the problem to the
patient and give them a major part in any decision to
maintain or remove the implant when an MRI suggests
rupture. Therefore, the ultimate decision to remove or
retain such an implant is a collaborative decision between
the patient and the surgeon.
INDICATIONS FOR EXPLANTATION
Patients request explantation for a multiplicity of condi-
tions. The primary reasons for implant removal are listed
in Table 4-2. The most common indication in my practice
152
Reoperative Plastic Surgery of the Breast
FIGURE 4-9. Characteristic “snowstorm” appearance of an
extracapsular rupture as imaged by breast sonogram.
FIGURE 4-10. The characteristic stepladder sign of intra-
capsular rupture of a silicone gel implant seen with breast
sonography.
FIGURE 4-11. MRI image of a breast implant that displays an
intracapsular rupture showing the linguini sign. This indicates
that the shell of the implant has come to lie in the substance of
the gel that is contained within the periprosthetic capsule
around the device.

Chapter 4
Evaluating Implant Integrity and Explantation Options and Techniques
153
is that of implant rupture or suspected rupture, which is
normally suggested by a combination of history, physical
examination, and most importantly the breast imaging
findings as noted earlier. Additional implant-related prob-
lems leading to explantation are local pain or discomfort;
capsular contracture, which may produce breast distor-
tion; implant malposition; breast asymmetry; and patient
desire for an increase in size. Anxiety about the silicone
gel breast implant is no longer anywhere near as common
an indication for implant removal as it was in the early
part of the 1990s.22
To reiterate what we have just discussed, it is impera-
tive for the plastic surgeon to listen carefully to every
patient with a self-perceived or radiologically established
problem with a previously placed breast implant and to
perform a thorough evaluation of each patient. This evalu-
ation must be focused on making a diagnosis. I have
removed implants for all of the reasons cited previously.
In my experience the most common reasons for removal
and reinsertion of an implant are actual or suspected
implant rupture and advanced (Baker III or IV) capsular
contracture.
When encountering patients with anxiety related to a
previously placed breast implant, it is very worthwhile to
spend time “being a doctor” and reassuring patients about
what has been published in the peer-reviewed medical lit-
erature regarding the safety of silicone implants because in
all likelihood the patient has been exposed to a lot of
adverse and completely unfounded conjecture about
potential side effects of silicone breast implants found in
the lay press, on the Internet, and in television media.1,22 At
the time of this writing all of the scientific evidence3–9
shows that there is no link between the presence of silicone
in the body and the production of any recognized disease
entity in humans. Also important is the fact that there are
very strong data to show that there is no connection
between silicone and the production of breast cancer in
humans.7,8 Similarly, several studies have demonstrated
that there is no link between silicone gel and the induction
of connective tissue disease.5,6 There are a number of other
symptoms that patients have been said to complain about,
such as fatigue, hair loss, and skin changes. These also do
not appear to be related in any sort of a consistent or
cogent way to the presence of a silicone gel breast implant.
If, despite these reassurances, the patient persists with
any questions about the severity of constitutional symp-
toms and the presence of other medical problems and
their potential relationship to her implant(s), I will most
often recommend a formal consultation with an internal
medicine specialist for an additional evaluation.
Preferably this referral should be to a well-trained, experi-
enced internist with special knowledge in rheumatology
who keeps current with the medical literature regarding
silicone gel breast implants.
IMPLANT FAILURE
Failure of a breast implant means either deflation of a
saline implant or rupture of a silicone gel device. The for-
mer problem is most often immediately obvious to the
patient, who notes a decrease in breast fullness on the
affected side. A deflation rate of 1% to 2% per year per
implant appears to be an accurate description of the cur-
rent failure rate for these saline devices.23
The rupture rate for silicone gel implants is much
more difficult to accurately characterize. This is because
the majority of these device failures are related to a small
tear in the elastomer shell, after which the gel is con-
tained within the periprosthetic scar tissue capsule. This
produces the so-called silent or intracapsular implant
rupture, which is most often asymptomatic and not
reported. In addition, the data used to compute silicone
gel implant rupture prevalence are derived from the
patient seeking treatment for new symptoms, changes
noted in breast appearance, or patients presenting after
an abnormal imaging study of the breast implant.
Therefore the sample of patients used in the calculation
of the rupture incidence is a biased self-selected cohort.
What is needed is a prospective study relying on careful
follow-up examinations and MRI studies. Such data are
beginning to evolve from at least two of the Scandinavian
countries, namely Denmark24,25 and Finland.
At present it is fair to say that the incidence of silicone
gel implant failure increases with time.26 Many surgeons
believe that the chance of rupture probably approaches
50% once the prosthesis has been in place for 12 years or
more.27
TREATMENT OF IMPLANT FAILURE
When a saline implant deflates, it is immediately apparent
to the patient, who notices less breast fullness. This most
often rapidly progresses to total deflation. When this situ-
ation is reported to the plastic surgeon early in its course
(within the first several days), the procedure to replace the
implant is straightforward and can most often be done
through a small incision under local anesthesia. Minimal
TABLE 4-2 Indications for Explantation
●Rupture
●Symptomatic capsular contracture
●Pain
●Breast distortion
●Implant malposition
●Patient requests change
●Patient anxiety or fear about implant-induced diseases

capsulotomy incisions (or none at all) in the capsule are
all that is needed if the problem is addressed promptly.
When such an event is neglected or not reported for
even 1 week, the capsular tissue begins to contract. This
sets up a situation where multiple capsulotomies or cap-
sulectomies and increased dissection are necessary to
restore the dimensions of the periprosthetic space. Such a
procedure usually requires a general anesthetic, and the
use of a drain may be involved. Therefore, after I inform
all of my patients about the rupture rate of saline
implants, I tell them that should such an event occur, they
should report it as soon as possible to minimize the degree
of surgery necessary to replace the implant.
Rupture of a silicone gel implant requires implant
removal and removal of as much of the silicone as possi-
ble. For an intracapsular rupture a total periprosthetic
capsulectomy (TPPC) essentially removes the gross sili-
cone. This then allows placement of a new implant, either
a silicone or saline device. An intracapsular rupture has
already been cited in the literature28 as an indication for a
TPPC (see below).
The situation of an extracapsular rupture is often a lit-
tle more involved in terms of the procedure needed to
remove the silicone. There is often a silicone granuloma,
which is an aggregate of scar tissue adjacent to the
periprosthetic capsule or within the breast tissue. This sit-
uation requires both a TPPC and resection of the silicone
granuloma, which may require a sacrifice of breast tissue.
In this situation I always mention to the patient that it
may be impossible to remove all of the silicone from her
breast tissue. Therefore, the possibility of residual silicone
in the breast tissue exists, and this may represent a nidus
for additional scar tissue deposition, resulting in a sili-
conoma or a mass in the breast that requires a workup
and most likely another surgical procedure for excision.
MANAGEMENT OF THE
PERIPROSTHETIC CAPSULE
After explantation is elected the surgeon must decide
whether to perform a complete capsulectomy at the time
of implant removal. In my practice I do this in almost
every case when a silicone gel implant is removed. Overall
I subscribe to the guidelines espoused and published by
Young28 in making decisions regarding capsulectomy.
The operation is routinely done (and best tolerated)
under general anesthesia. The procedure virtually always
involves a meticulous dissection of the periprosthetic cap-
sule away from the surrounding breast tissue. It is unusual
and generally unnecessary to sacrifice breast tissue unless
there is evidence of extracapsular rupture that has pro-
duced silicone granuloma(s), in which case the resection
of these extracapsular masses might include some breast
tissue, usually in the form of a small rim of the adjacent
breast tissue. Occasionally a small portion of the PMM
may require resection if a subpectoral implant rupture has
occurred, producing an extracapsular granuloma involv-
ing the muscle tissue.
Total periprosthetic capsulectomy can be carried out
using either an inframammary (IM) or a periareolar inci-
sion, though the latter is far more difficult. It cannot (and
should not) be done using an axillary incision. My stan-
dard approach is to use a pre-existing IM incision (Fig. 4-
12). It is usually necessary to make such incisions
considerably longer (Fig. 4-13) than the previous incision
used for breast augmentation. This should be explained to
the patient preoperatively.
If there is a planned mastopexy, which will entail either
a vertical or an inverted T (Wise) incisional pattern, the
154
Reoperative Plastic Surgery of the Breast
FIGURE 4-12. The customary approach is to use a previous
inframammary incision to perform the implant removal.
FIGURE 4-13. Often the inframammary incision must be
made considerably larger to provide the necessary exposure for a
complete capsulectomy.

Chapter 4
Evaluating Implant Integrity and Explantation Options and Techniques
155
capsulectomy can be performed through the vertical inci-
sion, which can be extended superiorly in continuity with
a portion of either a lateral or medial periareolar incision
(Fig. 4-14). In such a situation the new nipple position is
established first. Although this is usually above the upper
margin of the existing areola–breast skin junction, the ini-
tial incision must be kept below this point (Fig. 4-15).
Next a line is drawn along either the medial or lateral are-
olar border and is extended tangentially toward the IM
fold area in the midmeridian of the breast (perpendicular
to the IM fold) in a vertical orientation (see Fig. 4-15).
Some adaptation of these incisions will be used for either
a vertical or inverted T mastopexy. This unusual approach
tremendously facilitates the surgical exposure for the
TPPC (see Fig. 4-14). Following completion of the TPPC
and implant removal, either a mastopexy alone or an aug-
mentation mastopexy can be completed in a straightfor-
ward manner using the tailor-tacking method of
estimating breast shape (Fig. 4-16).
As noted, in general I prefer to remove as much of the
periprosthetic capsule as possible unless there is an
anatomic or surgical reason not to. I agree in general with
the indications for capsulectomy as outlined by Young.28
I believe that the periprosthetic capsule should be entirely
removed when there is evidence of a silicone gel implant
rupture to diminish the possibility of silicoma formation. In
any situation where an implant is strongly suspected to be
ruptured, complete or total capsulectomy is the best way of
removing all of the gross silicone and preventing or mini-
mizing any potential for silicone spill into the breast tissues
or the occurrence of residual silicone in the breast tissues.
I try to perform as much of the dissection as possible with
the implant within the capsule because I believe that this
facilitates the dissection. I also try to deliver the implant with
the surrounding capsule intact, which also limits the possi-
bility of residual silicone in the breast tissues (Fig. 4-17).
In addition, a TPPC should be performed if the capsule
is thick or calcified (Fig. 4-18), when an established sili-
cone granuloma is to be removed, when there is infection
around an implant, and when there is carcinoma adjacent
to the implant. More common indications in my practice
are for the treatment of a Baker III and Baker IV capsular
contracture or when exchanging a smooth device for a
textured implant regardless of the degree of capsular
FIGURE 4-14. Use of a vertical incision to facilitate a total periprosthetic capsulectomy in a patient
who will have a mastopexy as part of her treatment. This provides optimal exposure for the explantation.

156
Reoperative Plastic Surgery of the Breast
contracture. Finally, polyurethane-covered implants are
best removed by performing a TPPC.
In all cases surgical judgment must be exercised when
deciding to perform a complete capsulectomy because at
times it may be ill-advised to perform a TPPC procedure.
The most common example of this is when there is any
evidence of significant attenuation of the overlying
breast tissue. In such cases the dissection necessary to
complete the TPPC might lead to compromise in the vas-
cularity of the overlying skin tissues; wound breakdown;
and, if an implant replacement is requested by the
patient, implant exposure and ultimately implant loss.
This can occur in situations of long-standing subglandu-
lar breast implantation complicated by severe capsular
contracture with markedly thin overlying tissues. More
commonly, however, the circumstance of thin overlying
soft tissue with adherence of the implant to the tissue is
noted in the setting of a previous subcutaneous mastec-
tomy with implant reconstruction. This setting poses a
separate set of problems, especially if multiple incisions
have been made on the breast to diagnose breast
parenchymal lesions. Such a patient may be particularly
vulnerable to skin breakdown following a TPPC, and
hence it may be advisable to leave portions of the capsule
beneath the skin intact (Fig. 4-19). This situation is
FIGURE 4-16. The tailor-tacking maneuver is an ideal way to optimize breast parenchymal shape and
to estimate the amount of skin to be excised.
FIGURE 4-15. In designing mastopexy incisions the vertical
incision should hug the areolar margin and should not be
extended more superiorly than the upper margin of the areola.

illustrated by the patient shown in Figure 4-20, who pre-
sented to the office with left breast discomfort, a pro-
gressive deformity of the inferior pole of the breast, and
the MRI findings of an extracapsular rupture of a sili-
cone gel breast implant placed 26 years earlier as a form
of reconstruction after a subcutaneous mastectomy
(Fig. 4-20). Her treatment entailed an incomplete ante-
rior capsule resection so as to limit the possibility of
damaging the skin on the lower pole of the breast.
Suffice it to say, surgical judgment regarding treatment
of an established periprosthetic capsule must be exercised
for each individual patient who undergoes breast implant
removal.
Chapter 4
Evaluating Implant Integrity and Explantation Options and Techniques
157
FIGURE 4-17. Delivered breast implant with surrounding
periprosthetic capsule.
FIGURE 4-18. This explant specimen shows severe calcifica-
tion in the periprosthetic capsule. It is especially important to
remove such calcified capsules.
FIGURE 4-20. Previous subcutaneous mastectomy patient
who shows marked adherence of her breast skin to the capsules
in the inferior aspect of both breasts (arrow).
FIGURE 4-19. Explanted specimen in patient in Fig. 4-20.
Note a portion of the anterior periprosthetic capsule has been
left behind (arrow) to limit the possibility of injury to the skin of
the breast.

158
Reoperative Plastic Surgery of the Breast
TECHNIQUE OF CAPSULECTOMY
A capsulectomy is most easily performed using a generous
incision, a headlight and/or a lighted retractor for illumi-
nation of the breast wound, and the electrocautery device.
Using the cautery (in coagulation mode) will allow a sepa-
ration of the tissues at the capsule–breast tissue interface
and prevent injury to the implant. I use a Valleylab
(Valleylab, Boulder, Colo) electrocautery unit with the
coagulation mode set to 30 or 35.
The previous incision is reopened by excising the skin
scar. If an IM incision has been made, it most often needs
to be extended as mentioned earlier. The dissection is
deepened through the subcutaneous tissue and breast tis-
sue by inclining the plane of dissection slightly cephalad
so as not to inadvertently lower the IM fold and level of
the implant. The layer of the periprosthetic capsule is eas-
ily identified because it has a slightly bluish hue. The
plane between the capsule and surrounding tissue is
developed initially with the electrocautery set to coagula-
tion mode with illumination provided by a headlight or
lighted retractor.
When the IM incisional approach is used, the most dif-
ficult aspect of the capsulectomy procedure is the dissec-
tion over the top of the implant, where visibility is difficult
despite the use of multiple retractors and adequate illumi-
nation. This is often best accomplished by careful digital
dissection to separate the planes in this location. The sur-
geon must be careful when using digital dissection to not
create false passages into either the inside of the capsule
itself or the breast tissue. Using the technique illustrated
in Figure 4-21, the surgeon places his or her gloved index
fingernail on the capsule and presses down on the encap-
sulated implant. The edge of the surgeon’s fingernail is
used in a manner similar to a periosteal elevator. The
breast tissue is thereby elevated above the capsule with
the fingernail from the dome anteriorly extending superi-
orly to the superficial cephalic margin of the capsule edge.
This method of dissection may not be possible when frank
extracapsular rupture is present because the planes may
be sticky in this circumstance. Most often I have found
this maneuver very helpful in performing the dissection
on the upper part of the implant from an IM incision.
When the capsule has been completely freed from the sur-
rounding breast tissue, the capsule-encased implant will
have achieved a significant amount of mobility. At this
point it can usually be delivered through the wound below
(see Fig. 4-19).
Occasionally the implant cannot be delivered
through the wound below because of its size, degree of
encapsulation, or amount of calcification surrounding
it. At this point there are two options, namely to either
make the skin incision (which is longer than the previ-
ous skin incision) longer still or to perform a capsulo-
tomy and remove the implant contents before removing
the capsular tissue. The latter is usually the preferred
option, and it can be done with minimal to no silicone
gel spilling.
More commonly the problem is an inadvertent capsu-
lotomy with leakage of the silicone gel. Suture repair of
this small capsular rent with a 4-0 chromic suture on a
noncutting needle can be attempted. In my hands this is
often unsuccessful, and I then find it necessary to perform
a formal capsulotomy with a Bovie (Bovie Medical Corp.,
St. Petersburg, Fla) on coagulation mode or the electro-
cautery device (Valley Lake, Colo) by extending this small
rent in the capsule and removing the contents of the cap-
sule, namely the silicone gel and elastomer shell. Before
executing this maneuver the surgeon should have a kidney
basin in the operative field, along with a suction device, to
most expeditiously remove the free silicone material. It is
usually a good idea to change surgical gloves and some-
times the surgical instruments if they have been exten-
sively coated with silicone. Following the removal of this
material the remainder of the capsulectomy is completed,
again with care being taken to remove capsular tissue only,
while preserving breast and PMM tissue. Hemostasis
should be sought and obtained as the capsular tissue is
removed and the interface of the muscle or breast tissue
has a chance to retract. I find that using the capsular tis-
sue as a handle prevents retraction of the breast
parenchyma and muscle tissue deep within the wound
(superiorly and laterally). Therefore, meticulous hemosta-
sis should be obtained before completely delivering the
capsule. A suction drain (10-mm Jackson-Pratt [Ethicon,
Inc., Somerville, NJ]) is placed in all cases.
FIGURE 4-21. Diagram illustrating the incorrect (A) and
correct (B) way of performing finger dissection to achieve
periprosthetic capsule removal.

SUMMARY STATEMENT
ON CAPSULECTOMY
Is it necessary to remove the entire capsule? It is helpful to
remove the capsular tissue completely, especially in the
situation of implant rupture. But it is not imperative that
all of this periprosthetic scar tissue be removed in every
case. This pertains most often to the area of the posterior
capsule in cases of previous subpectoral implantation
where the capsule may be quite adherent to the chest wall.
It is important to avoid injury to the cartilage, rib, or inter-
costal musculature of the chest wall or risk the production
of a pneumothorax while removing the capsular tissue. As
implied, the surgeon will encounter the occasional case
where the planes are very indistinct, and in these situa-
tions it is better to leave small areas of capsular tissue
adherent to the chest wall than to risk chest wall injury. As
previously noted, the same holds true for patients with an
extremely thin layer of breast tissue and skin where the
assiduous removal of capsular tissue might result in dam-
age to the overlying skin. This situation is most commonly
encountered in the setting of a previous subcutaneous
mastectomy where the majority of the breast tissue has
been removed. An additional hazard for producing tissue
loss is the presence of scars on the breast skin from previ-
ous biopsies that are commonly seen in patients who have
undergone subcutaneous mastectomy.
Finally, it may be helpful to maintain remnants of the
capsule to use in a capsular flap repair (Chapter 3) or to
serve as a better anchor for sutures used for a capsulor-
rhaphy technique when it is necessary to alter the dimen-
sions of the periprosthetic capsular space. This is
particularly important when the surgeon needs to either
raise the level of the lower pole of the implant or position
the implant in a more medial location by closing down the
lateral periprosthetic capsular space with sutures.
TREATMENT OPTIONS FOLLOWING
EXPLANTATION
Treatment options for patients who desire or require
explantation are as follows: explantation alone without the
placement of new implants, explantation with reinsertion
of new breast implants (most often saline, but in the
United States such patients are candidates for replacement
with silicone gel implants under the FDA adjunct study of
silicone-filled breast implant protocols), mastopexy alone
without new implant placement, mastopexy done at the
time of the reinsertion of new implants (augmentation
mastopexy), and autogenous conversion. The latter option
is most often (almost exclusively) performed in patients
who have undergone previous implant-based breast recon-
struction. These options (Table 4-3) must be individualized
for the specific patient and her needs. In my experience the
insertion of new implants is by far the most commonly
requested option.21 Explantation alone is the next most
commonly requested procedure, but it is relatively rare
among patients less than 50 years of age.
EXPLANTATION ALONE
In my experience the option of explantation alone is cho-
sen by approximately 20% of patients undergoing breast
implant removal. It produces a significant change in the
patient’s body image, and it is imperative that this be com-
municated to the patient preoperatively. The surgeon
should have a firm belief that the patient clearly under-
stands this and is willing to accept this drastic change in
her appearance.
In my experience this option is most often chosen by
patients who are slightly older (>50 years), are psychologi-
cally stable and well-adjusted individuals, and have most
often been in long-term marital relationships. Even in this
subset of patients, the effect of explantation without new
implant insertion can precipitate feelings of depression. If
there is concern on the part of the surgeon preoperatively
that professional psychological support may be needed,
such arrangements should be undertaken preoperatively
or instituted early postoperatively if depression becomes
clearly evident.
As noted, the technique of explantation most often
involves lengthening the incision used to place the
implant. The procedure is most readily accomplished
through an IM incision (unless the areolas are very large),
and it should not be done through an axillary approach
unless the surgeon is removing saline implants and does
not plan to perform a capsulectomy. In the latter case the
use of the endoscope can facilitate implant identification
and removal. Capsulectomy in this setting is not neces-
sary, and therefore this approach is reasonable. As previ-
ously described, a capsulectomy procedure is greatly
facilitated with the use of a headlight and lighted retrac-
tor. The dissection is best done with the electrocautery
using the coagulation setting. Following implant removal
a suction drain is placed. I believe that it is important to
remove as much of the capsule as safely possible, espe-
cially in the setting of implant rupture, because the com-
bination of free gross silicone gel and retained capsular
tissue can predispose the patient to siliconoma forma-
tion. The drain is left in place until it drains less than 30
Chapter 4
Evaluating Implant Integrity and Explantation Options and Techniques
159
TABLE 4-3 Treatment Options Following Explantation
●Explantation alone
●Explantation with implant reinsertion
●Mastopexy alone
●Mastopexy plus new implant placement
●Autogenous conversion

160
Reoperative Plastic Surgery of the Breast
cc in a 24-hour period. I find it especially important to
adhere to this policy in this setting because there is no
potential tamponade effect provided by a breast implant,
and chronic seroma formation is a more likely possibility
following explantation without implant reinsertion.
A typical example of a patient electing explantation
without new implant placement is this 63-year-old
woman who had undergone bilateral subglandular breast
augmentation with silicone gel implants 26 years earlier
(Figs. 4-22 and 4-23). Her implants had become progres-
sively firmer and uncomfortable, especially when she lay
on them while sleeping. A sonogram suggested intracapsu-
lar rupture of the left breast implant. Her preoperative
examination demonstrated Baker IV capsular contracture,
but the breasts were relatively symmetric (Fig. 4-22A,B).
The patient decided to have her implants removed and did
not wish to have replacement. This produced the expected
significant change in her breast appearance (Fig. 4-23A,B).
FIGURE 4-22. Preoperative AP (A) and oblique (B) views of patient with hard, painful subglandular
silicone gel breast implants that were inserted 26 years before.
FIGURE 4-23. A–B, Patient elected to have bilateral explantation without new implant insertion.
Photos show the expected dramatic change in her breast appearance with complete lack of fullness.

Chapter 4
Evaluating Implant Integrity and Explantation Options and Techniques
161
EXPLANTATION WITH IMPLANT
REINSERTION
My experience over the past decade reflects the fact that
implant reinsertion is the most commonly chosen option
following explantation. In my practice approximately two
thirds of patients choose this option. It is by far the most
popular choice in patients less than 50 years of age who
have become accustomed to and enjoy the breast fullness
provided by implants. Patients in this age group most
often wish to maintain breast fullness after implant
removal.
Replacement implants can be either silicone gel–filled
or saline-filled devices. In the early 1990s this procedure
most commonly entailed the removal of a silicone gel
implant and replacement with a saline implant. This was
largely because of the public hysteria surrounding silicone
gel implants.1,23 Most recently many patients in my prac-
tice are requesting new silicone gel implants as replace-
ment devices. Regardless of which implant is chosen, every
patient is clearly informed that any replacement implant is
unlikely to last the course of her lifetime. That is to say that
implant shell disruption is a likely event at some point in
time. Patients are informed that the two most common
long-term complications of implant placement are capsu-
lar contracture29 and the need for reoperative surgery
(20% at 5 years).23 In addition, the known risks and com-
plications associated with the placement of breast
implants (outlined in Chapter 3) are carefully reviewed.
Initially the replacement saline implants were placed in
the same position as the silicone implants that were
removed. However, it soon became apparent that in
patients with an insufficient amount of their own breast
tissue, new implants placed in the subglandular position
often showed signs of implant visibility, including ripples,
ridges, and discernible edges of the implant. It is now very
apparent that patients who desire their replacement saline
implants be placed in the subglandular position must
have adequate tissue padding. It is necessary for the sur-
geon to make a determination preoperatively by using a
variation of the pinch test maneuver30 (Fig. 4-24)
described in Chapter 3. The surgeon must carefully pal-
pate the breast parenchyma overlying the implant by
grasping the tissue between the thumb, index, and middle
fingers (Fig. 4-24). I believe that a minimum of 2 cm of tis-
sue must be present to permit subglandular placement of
a new saline implant. If this is not the case, then the sub-
pectoral placement of the new implant is preferable.
When adequate tissue padding is present to allow
implant placement in the subglandular space and the
patient desires a saline-filled device, my preference is to
use a smooth-surfaced implant filled 10% to 30% beyond
the manufacturer’s maximum suggested fill volume. This
is the best way to minimize the tendency for rippling
along the edge of the implant. As noted in Chapter 3,
saline implant selection is based on a patient’s dimensions
and requires careful measurement of the base width of the
breast, the height of the breast, and the distance from the
NAC to the IM fold (see Fig. 3-2).
In the absence of performing a mastopexy, when a
new implant is placed into the same position as the
implant that has just been removed, the new implant is
generally slightly larger in size (dimension and volume)
than the previous indwelling implant. This is because the
dissection entailed with capsulectomy and implant
removal always increases the dimensions of the peripros-
thetic space to some degree. It is important to point this
out to the patient preoperatively. When using a saline
implant as the replacement device following removal of a
silicone gel implant, I believe that it is important to avoid
implant–pocket disproportion, i.e., to relatively precisely
FIGURE 4-24. The pinch test is done to allow the surgeon to
estimate the amount of breast tissue in the upper aspect of the
breast. It is important to do this in both primary and secondary
cases involving breast implants.

162
Reoperative Plastic Surgery of the Breast
fill the dissected pocket with the new implant. As stated
in Chapter 3, I believe that this is an important factor in
minimizing the problem of rippling or visible folds
related to the saline implant placement.
If the removed implant was originally in the subglan-
dular position and the new implant is positioned in the
retropectoral location, it is important to close down the
subglandular plane by suture fixation of the PMM to
the overlying breast parenchyma (Fig. 4-25A,B). This
provides the best assurance that the implant will
remain in the submuscular position and not slip back
into the subglandular space. This is especially impor-
tant if a smooth-walled saline implant is used. Suture
closure of the space is easily accomplished with 3-0
coated polyglycolic acid sutures on a noncutting
needle [PDS (Ethicon, Inc., Somerville, NJ) or Maxon
(Sherwood-Davis & Geck, St. Louis, Mo); Fig. 4-25B]. It
is important not to dimple the overlying skin tissue with
this suture placement in patients with very thin breast
parenchyma.
As mentioned, I believe that most of the capsulec-
tomy dissection is best performed with the electro-
cautery device using the coagulation mode, along with
some element of digital dissection. The Bovie enables
the surgeon to achieve optimal hemostasis. Similarly, it
is my custom to perform additional periprosthetic cap-
sular space modification and PMM elevation proce-
dures with electrocautery. A multiple-layered wound
closure with polyglycolic acid suture is used, and a suc-
tion drain is always placed. This is introduced through
a laterally positioned stab incision, which when possi-
ble is located in the shadow of the breast in the position
of the bra line. I prefer to use a 10-mm Jackson-
Pratt or BLAKE drain (Ethicon, Inc., Somerville, NJ).
The drains are maintained in position until the out-
put from the drain is less than 30 cc per 24 hours. While
the drains are in place the patient is kept on oral antibi-
otics and is instructed to keep the drains clean and
dry. Patency of the tubing is facilitated by stripping or
milking the drainage tube several times each day.
Drainage through the Jackson-Pratt drains of more
than 30 cc per day often persists for 10 to 14 days
postoperatively.
Drains are important to prevent seroma accumulation
and minimize the development of a biofilm around the
implant, thereby allowing the best chance of healing
between the newly placed implant and the adjacent tis-
sue interface. This is especially important if a textured-
surface implant is used. Following drain removal the
patient is permitted to shower and she is instructed to
wear a bra 24 hours a day for breast support for the ensu-
ing 4 weeks. Additionally, the patient is asked to avoid
FIGURE 4-25. Surgical maneuver to suture close the subglandular space in cases in which there will
be a conversion of a subglandular to a subpectoral implant position. This is shown diagrammatically
(A) and in the operating room in the accompanying photo (B).

Chapter 4
Evaluating Implant Integrity and Explantation Options and Techniques
163
any bouncing activities for a total of 6 weeks. This is
done to minimize the risk of delayed hematoma forma-
tion or the possibility of seroma fluid accumulation
around the implant. If a smooth-walled implant is used,
the displacement exercises outlined in Chapter 3 are
instituted 2 days following drain removal, and they are
continued forever.
In my opinion the easiest and best way of optimizing
breast aesthetics following implant removal in most
patients is by implant reinsertion. This involves the
minimum number of incisions, and the ones that are
made are most often concealed. The typical case scenario
is illustrated by the following three cases.
This first patient presented 11 years after undergoing
a subglandular silicone gel breast augmentation with a
Baker IV capsular contracture of the right breast
implant. She was bothered by the distortion of the breast
and the associated discomfort (Fig. 4-26) and requested a
surgical procedure to improve the appearance of the
breasts. She underwent a bilateral TPPC and removal of
her severely encapsulated implants through an IM inci-
sion. She had the placement of new smooth-walled sili-
cone gel implants placed in the subpectoral implants.
These were 300-cc regular-profile implants with a base
width of 12.1 cm. This procedure produced a good
restoration of symmetry, a return of softness to the
breasts, and an overall excellent appearance to the
breasts (Figs. 4-27A,B and 4-28A,B), albeit with a longer
IM incision (Fig. 4-29).
FIGURE 4-26. Baker IV capsular contracture in right breast 11
years following subglandular silicone gel breast augmentation
with obvious distortion and asymmetry.
FIGURE 4-27. Preoperative (A) and postoperative (B) AP views
at 2 years.

164
Reoperative Plastic Surgery of the Breast
FIGURE 4-28. Preoperative (A) and postoperative (B) lateral views at 2 years.
FIGURE 4-29. The patient has a longer but almost impercepti-
ble IM incision.

Chapter 4
Evaluating Implant Integrity and Explantation Options and Techniques
165
This next patient was referred by the radiology depart-
ment after a mammogram and sonogram of the breasts
suggested an extracapsular rupture of a previously placed
subglandular silicone gel breast implant (Fig. 4-30A,B).
She underwent TPPC and removal of both the capsules
and the previously placed implants (Fig. 4-31). She then
had the insertion of saline implants placed in the subpec-
toral position. Before assigning the implants to the new
position, the subglandular space was closed with sutures.
This treatment produced a marked improvement in overall
breast aesthetics (Fig. 4-32A,B).
The final patient illustrates the point that, occasionally,
a patient will undergo explantation initially without
implant reinsertion and then at a later date she may elect
to have breast implants replaced. This 45-year-old patient
had a previous subglandular silicone gel breast augmenta-
tion with smooth-walled implants. She was found to have
probable extracapsular rupture of her right breast implant
on a sonogram done 16 years after the procedure. She had
a Baker IV on the left side as well (Fig. 4-33A,B). After con-
siderable deliberation she underwent removal of her
implants without reinsertion (Fig. 4-34A,B). She was
bothered by the change in her breast appearance and 3
years later she underwent redo breast augmentation with
360-cc smooth-walled saline implants placed in the partial
retropectoral position (Fig. 4-35A,B). This case illustrates
that patients who have undergone explantation following
a breast augmentation initially without reinsertion of new
implants always have subsequent breast implant place-
ment as an option.
FIGURE 4-30. This is a 44-year-old female 9 years following bilateral subglandular silicone gel aug-
mentation mammoplasty with bilateral capsular contracture and suspected rupture of her right breast
implant. A, AP view. B, Lateral view.

166
Reoperative Plastic Surgery of the Breast
FIGURE 4-31. A, Preoperative skin markings for palpable mass in the upper outer aspect of her right
breast. B, Explantation specimen with silicone granuloma resected in continuity with capsule of right
breast implant.
FIGURE 4-32. Very satisfactory aesthetics restored by reinsertion of silicone gel implants into sub-
pectoral position. A, AP view. B, Lateral view.

Chapter 4
Evaluating Implant Integrity and Explantation Options and Techniques
167
FIGURE 4-33. This 45-year-old patient presented 16 months after previous bilateral silicone gel aug-
mentation. She had bilateral Baker III capsular contracture and suspected rupture of right breast
implant. A, AP view. B, Oblique view.
EXPLANTATION WITH MASTOPEXY
ALONE
Often the plastic surgeon encounters patients who had
their breast implants placed in their late teens or early
twenties and who present for evaluation of an implant
problem in their late thirties or early forties. In the inter-
vening 15 to 20 years many of these patients have gained a
significant amount of weight (20 to 30 lb) since their
breast augmentation. Most often there will be a corre-
sponding increase in the patient’s breast volume to the
point where explantation with mastopexy alone (without
new implant insertion) becomes a feasible and realistic
option. This plan almost always provides a satisfactory
breast shape, albeit with scars in either a vertical
mammaplasty or an inverted T incisional pattern.
The surgeon must carefully evaluate the patient preop-
eratively to determine the amount of breast parenchyma
present. This is done by distracting the breast tissue away
from the implant with the examiner’s fingers (Fig. 4-36).

168
Reoperative Plastic Surgery of the Breast
FIGURE 4-34. Patient had explantation alone, which resulted in a decreased breast size. A, AP view.
B, Oblique view.
FIGURE 4-35. Patient had a delayed subsequent redo breast augmentation with smooth-walled saline
implants placed into the subpectoral position. This produced a very nice appearance of the breasts.
A, AP view. B, Oblique view.

Chapter 4
Evaluating Implant Integrity and Explantation Options and Techniques
169
This is the best method of estimating the volume of breast
parenchyma and also the best way to evaluate it for breast
pathology. The surgeon can then demonstrate to the
patient how much breast tissue is available to recreate the
breast without replacing the implant, emphasizing that
the new breasts will be smaller.
If the patient is content with a smaller size and will
accept more extensive scars on the breasts, then explanta-
tion with mastopexy alone is an option. In my practice
mastopexy in this setting can be done using either a verti-
cal incision technique or an inverted T incisional pattern.
With either option a vertical incision between the areola
and the IM fold is part of the operative approach (see
Fig. 4-14). This vertical incision provides excellent expo-
sure for performing a complete capsulectomy. A small
portion of one side of a periareolar incision can be used as
part of the incision for capsulectomy.
Regardless of approach, careful pedicle selection with
a plan to maximally preserve nipple areola blood supply is
paramount. In most instances the surgeon can choose
between a superior, inferior, medial, or lateral pedicle—or
combinations of these. Once again a word of caution is in
order. That is, the surgeon must be very wary of perform-
ing an aggressive mastopexy with a significant nipple
transportation if a subglandular augmentation has been
performed due to its interference with nipple areola blood
supply (Fig. 4-37). This warning goes double in a smoking
patient, where the danger of tissue necrosis is extremely
great with this approach.
Once the decision is made to proceed with a mastopexy
following explantation, establishing the correct new nipple
position is the most important step. After a previous breast
augmentation the nipple position may be too high, too low,
or appropriate. Precisely establishing the new nipple posi-
tion before the explantation is tricky due to the anticipated
decrease in breast volume. However, an estimate must be
made, and the apex of the vertical incision used for the
explantation (in fact for all incisions) should be kept below
this position (see Fig. 4-15). The only mistake that the sur-
geon must avoid is placing the initial incisions used for the
explantation portion of the procedure too high. My experi-
ence is that the nipple position can be estimated by meas-
uring the proposed new nipple from the fixed point of the
SSN. The surgeon can measure between 21 and 25 cm
from the SSN depending on the patient’s height in inches,
as indicated in Table 4-4.
I use these distances as estimates only. The final estab-
lishment of the nipple position is best done after the
explantation and reconfiguration of the breast tissue with
the patient sitting up at 90 degrees on the operating table.
This is the position that is necessary to make an accurate
estimate of appropriate nipple position.
The breast tissue should be reconfigured to produce
the best possible shape by narrowing the base dimension
and optimizing projection of the breast. This usually
entails central transposition of de-epithelialized segments
of lateral and medial breast tissue (see Fig. 4-35A) or clo-
sure of medial and lateral pillars, which narrows the base
dimension of the breast and increases breast projection.
This is coupled with tailor tacking of the breast skin.
Alternatively, projection of the smaller, uplifted breast
mound may be optimized with a superior pedicle
mastopexy technique (using either a vertical or an
inverted T skin incision pattern) using a de-epithelialized
inferiorly based rectangular flap of subcutaneous and
breast tissue (Fig. 4-38) as a foundation on top of which
FIGURE 4-36. Method of evaluating the volume of a patient’s
own native breast tissue in the presence of a previous breast
augmentation.
FIGURE 4-37. The presence of a subglandular implant signifi-
cantly decreases the blood supply to the NAC. The surgeon must
bear this in mind when planning a mastopexy in the setting of a
previous subglandular breast augmentation.

the superior pedicle is seated (Fig. 4-39). These are stan-
dard maneuvers to improve breast shape and increase
projection when revising a mastopexy or a breast reduc-
tion and will be reviewed in Chapter 5.
Examples of the previous surgical approach for an
inverted T and vertical scar mastopexy are illustrated by
the following case. This patient presented at age 45 with a
suspected rupture of her right breast implant after a mam-
mogram and sonogram of the breasts. She had undergone
a bilateral subglandular breast augmentation using an
infra-areolar incision for postpartum involutional change
of the breasts at age 27. She had gained approximately 25
lb over the 17 years and her breasts were a D cup in size
and exhibited grade II mammary ptosis (Fig. 4-40A,B).
The plan was for implant removal and mastopexy alone
using an inverted T incisional pattern. The TPPC was per-
formed through the vertical incision while excellent expo-
sure was afforded during that part of the procedure
(Fig. 4-41). Because of the infra-areolar incision, a supe-
rior pedicle technique was selected for the mastopexy. The
tissue inferior to the areola was de-epithelialized and
served as a platform on top of which the reconfigured
breast tissue was seated. A tailor-tacking procedure was
used to establish the final incisions (Fig. 4-42A,B), and the
NAC was positioned at the appropriate height. The patient
exhibited smaller but well-shaped symmetric and aesthet-
ically pleasing breasts postoperatively (Fig. 4-43A,B).
The vertical scar mammoplasty32,33 has increasing
application in this setting, as illustrated by the following
patient who requested explantation for symptomatic cap-
sular contracture (Fig. 4-44A–C). Twenty-two years before
her consultation she underwent a bilateral subglandular
augmentation. She did well for many years and was
pleased with the result. She experienced an interval weight
gain of 15 lb and eventually developed a Baker III capsular
contracture on the right side and a Baker IV on the left,
which was marked by discomfort in the left breast. She
requested implant removal and desired a decrease in
breast size and a breast uplift. She was marked for a supe-
rior dermoglandular vertical mastopexy (Fig. 4-45).
She underwent a total periprosthetic capsulectomy
done through the vertical incision and had a superior
pedicle vertical mastopexy. The skin inferior to the areola
was de-epithelialized and the subcutaneous tissue and
breast parenchyma of the central lower breast was folded
up underneath the nipple and areola (Fig. 4-46) to maxi-
mize upper breast volume. Closure of the medial and lat-
eral pillars optimized upper pole fullness (Fig. 4-47). She
exhibited a very satisfactory result at 2 years following
surgery (Fig. 4-48A–C). The advantages of this technique
are that it both minimizes the skin scars and in my opin-
ion optimizes shape. This is because of the suture fixation
of the pillars of the breast parenchyma. It is a good tech-
nique for patients desiring an uplift only following explan-
tation.
170
Reoperative Plastic Surgery of the Breast
FIGURE 4-38. Autoaugmentation of the breast can be achieved
following explantation when mastopexy is planned without a
new implant. An inferiorly based rectangular flap of skin and
subcutaneous tissue and breast tissue is de-epithelialized and
mobilized to its pedicle.
FIGURE 4-39. This flap can be inserted beneath a superior
pedicle used for a mastopexy to increase the projection and
apparent volume of the breast. The flap is tacked to the chest
wall with 3-0 PDS suture.
TABLE 4-4 Estimating Nipple Position Based on
Patient Height
Patient Height (in)
Distance from SSN to Nipple
(cm)
58–62
21
62–66
22–23
66–70
24–25
70–72
25–26
SSN, Suprasternal notch.

Chapter 4
Evaluating Implant Integrity and Explantation Options and Techniques
171
FIGURE 4-41. A mastopexy without new implant insertion is
planned. The explantation is performed through the anticipated
vertical incision of the mastopexy.
FIGURE 4-42. A-B, Tailor tacking of the parenchyma and skin
is done to estimate optimal shape of the gland for mastopexy and
to guide skin excision.
FIGURE 4-40. A-B, 45-year-old patient with large, dependent, subglandular silicone gel implants
inserted through an infra-areolar incision into the subglandular space. She presented with bilateral
capsular contracture.

FIGURE 4-43. Postoperative appearance at 9 months demonstrates excellent breast shape and sym-
metry. A, AP view. B, Oblique view.
FIGURE 4-44. Preoperative appearance of patient who had a
subglandular silicone gel breast augmentation 15 years earlier.
She has gained 15 lb, has bilateral Baker III capsular contrac-
ture, and desires explantation and mastopexy only without new
implants. A, AP view. B, Lateral view. C, Oblique view.

Chapter 4
Evaluating Implant Integrity and Explantation Options and Techniques
173
FIGURE 4-45. Marking is done for superior dermoglandular
pedicle vertical mastopexy.
FIGURE 4-47. Closure of the pillars and reshaping of the
breast.
FIGURE 4-46. Operative photograph following explantation
and elevation of a superior and medial pedicle.

174
Reoperative Plastic Surgery of the Breast
FIGURE 4-48. Two years postoperative photographs demon-
strate a satisfactory appearance on, A, AP, B, lateral, and C,
oblique views following this vertical mastopexy.

EXPLANTATION WITH AUGMENTATION
MASTOPEXY
As previously noted, most women who experience a prob-
lem with their implant(s) that necessitates removal wish to
retain their breast fullness. This is also true for patients who
have the additional problem of settling of their breast tissue
away from the implant, producing the appearance of ptosis.
In these patients redo breast augmentation combined with
mastopexy is most often the treatment of choice.
The principles of this approach have been discussed in
the previous three sections and include a careful plan for
accurate positioning of the nipple and selecting the appro-
priate pedicle to carry it to its new position. In addition,
management of the new implant placement is important.
The options for implant reinsertion include maintain-
ing it in its original position and placing it in a new posi-
tion by reassigning it to a different position. When
operating to treat a ruptured prosthesis, if the implant
was in the subglandular position and there is sufficient
breast tissue overlying it and if there is more than 2 cm of
padding tissue, it may be feasible to maintain the implant
in this position. The same is true when the previous
implant was in the subpectoral space. However, if there is
insufficient or attenuated breast tissue, or if the procedure
is being done to treat capsular contracture, then a pocket
reassignment, i.e., converting a previous subglandular
implant to the subpectoral position before performing a
mastopexy, is often an advisable strategy.
Most often this maneuver involves relocating a previous
subglandular implant to the subpectoral position, which
entails releasing the origin of the PMM from the ribs inferi-
orly before performing the mastopexy. As noted previously,
in this situation I believe that it is helpful to suture the previ-
ous subglandular space closed (see Fig. 4-25A,B) as the inci-
sions used for the mastopexy are closed. This prevents the
implant from slipping back into the subglandular position.
The following patient who was treated for posttrau-
matic silicone gel implant rupture illustrates many of
these points. This 44-year-old female had undergone a
bilateral subglandular breast augmentation with smooth-
walled silicone gel implants 8 years earlier. She was
involved in an automobile accident that caused chest
trauma and resulted in a rupture of her right breast
implant. She presented for consultation with an obvious
deformity of the right breast (Fig. 4-49A–C) and an obvi-
ous asymmetry. She was also noted to have some settling
of her breast parenchyma away from the implants. She
was marked for a redo augmentation mastopexy with
implant reassignment and TPPC. Her markings are illus-
trated in Figures 4-15 and 4-50. She underwent a peripros-
thetic capsulectomy and focal removal of silicone, which
was dispensed into the surrounding breast parenchyma.
She then had insertion of saline implants into the subpec-
toral position, suture closure of the subglandular space,
Chapter 4
Evaluating Implant Integrity and Explantation Options and Techniques
175
FIGURE 4-49. Patient 8 years following bilateral subglandular
breast augmentation with silicone gel implants. She sustained a
trauma to the right breast with MRI-proven rupture of her right
breast implant. She is seen with distortion of the right breast and
settling of the tissue away from the implants. A, AP view. B,
Lateral view. C, Oblique view.

176
Reoperative Plastic Surgery of the Breast
and a simultaneous mastopexy using a superior pedicle
technique. Combining a redo breast augmentation and a
mastopexy adds to the complexity of the procedure. It is
indeed a balancing procedure, which in my hands
requires adjustments made on the operating table using
the tailor-tacking technique (see Fig. 4-16). Time spent fin-
ishing the procedure most often pays dividends in
optimizing breast appearance and symmetry. This resulted
in restoration of a good breast shape and symmetry
(Fig. 4-51).
The results of this combination are often gratifying for
the patient and the surgeon. As previously noted, I am
careful to never promise precise breast symmetry to the
patient, and I always explain that the immediate postoper-
ative appearance will change with time and that recurrent
ptosis is a likely outcome.
FIGURE 4-50. Markings for inferior pedicle mastopexy,
oblique view.
FIGURE 4-51. Patient shown in Fig. 4-49 underwent TPPC,
reinsertion of subpectoral saline implants, and inferior pedicle
mastopexy with inverted T incisional pattern. She is pictured
in AP view (A), lateral view (B), and oblique view (C) 2 years
following surgery.

Chapter 4
Evaluating Implant Integrity and Explantation Options and Techniques
177
EXPLANTATION WITH AUTOGENOUS
TISSUE CONVERSION
Removing a previously placed breast implant and substi-
tuting in its place the patient’s own tissue is a treatment
option that is largely limited to the setting of breast recon-
struction. This is due to the incisions necessary to harvest
and transfer such tissue; potential additional attendant
donor-site morbidity; and the expense of such surgery,
which is rarely covered by medical insurance.
The most common donor area is the lower abdominal
region in the form of a transverse rectus abdominis muscle
(TRAM), deep inferior epigastric artery perforator (DIEP),
or superficial inferior epigastric artery (SIEA) flap.
Additional options are the gluteus maximus musculocuta-
neous flap, the superior gluteus artery perforator (SGAP)
flap, the Rubens flap, and flaps derived from the circum-
flex scapular artery system. For the breast reconstruction
patient with available donor tissue and a previously com-
prised implant, reconstruction autogenous conversion is
an excellent treatment option.
AUTOGENOUS CONVERSION
FOLLOWING PREVIOUS BREAST
AUGMENTATION
Autogenous conversion is a decidedly uncommon option
for the reasons enumerated earlier. However, I have
encountered three patients in whom we were able to obtain
insurance coverage for such surgery following a complica-
tion from breast augmentation. One of these was a 51-year-
old female who developed bilateral breast pain and a Baker
IV contracture secondary to severely calcified peripros-
thetic capsules around her implants (Fig. 4-52A,B). She
requested autogenous conversion, had excess tissue in her
lower abdomen, and would tolerate the scars and potential
morbidity of conversion to bilateral TRAM flaps (Fig. 4-53).
The flaps were elevated as superior pedicle flaps and trans-
ferred (Fig. 4-54).
The plan was accomplished without complications,
and the patient demonstrated a very satisfactory long-
term outcome. This is illustrated by the appearance of her
breasts and abdomen in this photograph 10 years follow-
ing surgery (Fig. 4-55).
The conversion of a cosmetic procedure into a recon-
structive one is a very big step for both the patient and the
surgeon. From the patient’s standpoint there are virtually
always additional scars and contour deformity that may be
construed as additional disfigurement. The patient must
be informed of and very clear about this before surgery.
This is a big step for the surgeon, whether he or she
was the initial surgeon or a subsequent surgical consult-
ant. It is essential for the surgeon to clearly communicate
the plan to the patient and to precisely record this com-
munication in the consultation notes. In addition, it is
important to document the risks and consequences of the
proposed operation in the preoperative consent for the
planned surgery.
FIGURE 4-52. A-B, Patient 20 years following bilateral sub-
glandular breast augmentation with smooth silicone gel implants.
She has extremely hard, uncomfortable, immobile implants
bilaterally (Baker IV). She desires removal and reaugmentation
with her own tissue.

178
Reoperative Plastic Surgery of the Breast
FIGURE 4-53. The plan was to perform bilateral de-epithelial-
ized TRAM flap augmentation of each breast following implant
removal.
FIGURE 4-54. The TRAM flaps are superiorly based. The right
flap is shown de-epithelialized and the left flap has been trans-
ferred.

Chapter 4
Evaluating Implant Integrity and Explantation Options and Techniques
179
AUTOGENOUS TISSUE CONVERSION
FOLLOWING SUBOPTIMAL IMPLANT-
BASED BREAST RECONSTRUCTION
Autogenous tissue conversion is most common following
a compromised implant breast reconstruction, but it has
not been all that common in my practice. It was employed
mainly to treat problems of asymmetry due to capsular
contracture, implant rupture, quantitative and qualitative
skin deficiencies, volume deficit, and combinations of
these problems.
In my practice the pedicled TRAM flap has been the
mainstay for this treatment strategy, although the pedicled
latissimus dorsi flap (autogenous latissimus) and other
free flaps are also options for some patients (Chapter 6).
In my practice the pedicled TRAM flap has been the
workhouse for autogenous conversion. A typical case is
this 46-year-old female (Figs. 4-56 and 4-57), who had
undergone a right subcutaneous mastectomy with
implant reconstruction following multiple biopsies of the
right breast showing atypical changes. She presented
with a marked breast asymmetry 6 years later related to a
ruptured right breast implant and left-sided macromastia
(Fig. 4-56A,B). She was treated with the combination of a
total periprosthetic capsulectomy, implant removal, con-
version to a TRAM flap for the right breast reconstruc-
tion, and a contralateral left breast reduction. This
bilateral breast surgery resulted in a markedly enhanced
breast symmetry that was stable at a 2-year follow-up
(Fig. 4-57A,B).
Autogenous tissue conversion is a valuable treatment
option following explantation in the breast cancer patient
who undergoes implant-based reconstruction. I predict
that autogenous conversion will become much more com-
mon with the expanded use of adjuvant radiation therapy
in the breast cancer patient population.
FIGURE 4-55. The patient maintains excellent sym-
metry of her naturally soft breasts on 10-year follow-
up.

180
Reoperative Plastic Surgery of the Breast
FIGURE 4-56. A significant breast asymmetry due to a rup-
tured right silicone gel implant used for right breast reconstruc-
tion following a subcutaneous mastectomy. A, AP view. B,
Lateral view.

Chapter 4
Evaluating Implant Integrity and Explantation Options and Techniques
181
FIGURE 4-57. The patient underwent autogenous conversion to
a TRAM flap on the right side and had a left mastopexy. Note the
markedly improved breast aesthetics. A, AP view. B, Lateral view.

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1. Larson DL, Anderson RC, Maksud D, et al. What influences
public perceptions of silicone breast implants? Plast Reconstr
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2. Kessler DA. The basis of the FDA’s decision on breast
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3. Institute of Medicine. Safety of Silicone Breast Implants.
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4. Independent Review Group. Silicone Gel Breast Implants: The
Report of the Independent Review Group. Norwich, UK: Her
Majesty’s Stationery Office; Crown copyright; 1998.
5. Gabriel SE, O’Fallon WM, Kurland LT, et al. Risk of connective-
tissue diseases and other disorders after breast implantation.
N Engl J Med. June 16, 1994;330(24):1697–1702.
6. Sánchez-Guerrero J, Colditz GA, Karlson EW. Silicone
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7. Berkel H, Birdsell DC, Jenkins H. Breast augmentation: a risk
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8. Deapen DM, Bernstein L, Brody GS. Are breast implants anti-
carcinogenic? A 14-year follow-up of the Los Angeles Study.
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9. Rohrich RJ. Safety of silicone breast implants: scientific
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104(6):1786–1788.
10. Eklund GW, Busby RC, Miller SH, et al. Improved imaging of
the augmented breast. AJR Am J Roentgenol. September
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11. Shestak KC, Ganott MA, Harris KM, et al. Breast masses in
the augmentation mammaplasty patient: the role of ultra-
sound. Plast Reconstr Surg. August 1993;92(2):209–216.
12. Harris KM, Ganott MA, Shestak KC, et al. Silicone implant
rupture: detection with US. Radiology. June 1993;187(3):
761–768.
13. Ahn CY, Shaw WW, Narayanan K, et al. Definitive diagnosis
of breast implant rupture using magnetic resonance imaging.
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14. Ahn CY, DeBruhl ND, Gorczyca DP, et al. Comparative sili-
cone breast implant evaluation using mammography,
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with 59 implants. Plast Reconstr Surg. October 1994;94(5):
620–627.
15. Baker JL Jr. Classification of spherical contractures. Paper
presented at: Aesthetic Breast Symposium; 1975; Scottsdale,
Arizona.
16. Leitch MA, Dodd GD , Costanza M, et al: American Cancer
Society guidelines for early detection of breast cancer:
Update 1997. CA Cancer J Clin. May–June, 1997;47(3):
150–153.
17. Silverstein MJ, Handel N, Gamagami P, et al. Mammographic
measurements before and after augmentation mammaplasty.
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18. Handel N, Silverstein MJ, Gamagami P, et al. Factors affect-
ing mammographic visualization of the breast after augmen-
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19. de Camara DL, Sheridan JM, Kammer BA. Rupture and
aging of silicone gel breast implants. Plasr Reconstr Surg.
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techniques to establish the diagnosis of implant rupture or
integrity; and patient satisfaction with treatment options fol-
lowing explantation of silicone gel implants. Paper presented
at: 75th Annual Meeting of the American Association of
Plastic Surgeons; May 1996; Hilton Head, SC.
21. Cheung KC, Greenfield ML, Walters M. Decision-analysis
methodology in the work-up of women with suspected sili-
cone breast implant rupture. Plast Reconstr Surg. September
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22. Palcheff-Wiemer M, Concannon MJ, Conn VS, et al. The
impact of the media on women with breast implants. Plast
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23. Cunningham BL, Lokeh A, Gutowski KA. Saline-filled breast
implant safety and efficacy: a multicenter retrospective
review. Plast Reconstr Surg. May 2000;105(6):2143–2149; dis-
cussion 2150–2151.
24. Henriksen TF, Holmich LR, Friis S, et al. The Danish Registry
for Plastic Surgery of the Breast: establishment of a nation-
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and investigation of breast surgery. Plast Reconstr Surg. June
2003;111(7):2182–2189; discussion 2190–2191.
25. Kjoller K, Holmich LR, Jacobsen PH, et al. Epidemiological
investigation of local complications after cosmetic breast
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48(3):229–237.
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Plast Surg. January 1995;34(1):1–6; discussion 6–7.
27. Rohrich RJ, Adams WP Jr, Beran SJ, et al. An analysis of sili-
cone gel-filled breast implants: diagnosis and failure rates.
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28. Young VL. Guidelines and indications for breast implant cap-
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884–891; discussion 892–894.
29. Gabriel SE, Woods JE, O’Fallon WM, et al. Complications
leading to surgery after breast implantation. N Engl J Med.
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30. Tebbetts JB. Patient evaluation, operative planning, and sur-
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and reoperations in breast augmentation. Clin Plast Surg.
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31. Lassus C. A 30-year experience with vertical mammaplasty.
Plast Reconstr Surg. February 1996;97(2):373–380.
32. Lejour M. Vertical mammaplasty: update and appraisal of
late results. Plast Reconstr Surg. September 1999;104(3):
771–781; discussion 782–784.
182
Reoperative Plastic Surgery of the Breast

183
◗Revision Surgery Following Breast
Reduction and Mastopexy
Anatomic Considerations 184
Preoperative Examination 184
General Comments Regarding Reoperative Breast
Reduction 187
Complications of Breast Surgery 187
Hematoma 187
Skin Flap Ischemia and Skin Loss 189
Seroma 192
Wound Separation and Open Wound
Formation 192
Cellulitis 195
Recurrent Cellulitis 196
Nipple Areolar Ischemia 196
Long-Term Complications 198
Dog Ears 198
Unattractive Scars Due to Hypertrophy or
Spreading Hypertrophic Scars 199
Scar Excision and Wound Reclosure 200
Fat Necrosis 200
Asymmetry 202
Volume Asymmetry 202
Nipple Areolar Complex Asymmetry 203
Nipple Retraction 206
Nipple Malposition 208
Inferior Nipple Malposition 213
Challenging Problems Following Breast
Reduction 213
Nipple Loss 213
Massive Fat Necrosis 214
Subsequent Volume Loss with Loss of Breast
Fullness 220
Redo Reduction 221
Redo Mastopexy 221
References 236
Breast reduction and mastopexy are two commonly per-
formed breast operations in which the surgeon’s goal is
the same: to produce symmetric breasts that have a pleas-
ing shape with round, sensate nipple areolar complexes
(NACs) that are appropriately positioned. The surgeon
attempts to produce breasts whose shape is preserved for
as long as possible and that have a minimum number of
well-positioned scars.
Both procedures entail a superior shifting of the breast
parenchyma with some degree of breast skin flap redrap-
ing. However, they differ in that in breast reduction the
goal must be achieved in the context of removing breast
tissue (often in large amounts) to afford the patient relief
of her macromastia-related symptoms, whereas in
mastopexy most often little or no breast tissue is removed,
and not uncommonly volume is added to the breast in the
form of an implant.
Achieving consistently good results in both the primary
surgical and reoperative setting entails a thorough analysis
of the breast morphology and tissue condition, precisely
identifying the correct new nipple position and producing
a well-designed and precisely executed operative plan.
C h a p t e r 5

184
Reoperative Plastic Surgery of the Breast
These surgical operations are almost always a one-stage
procedure in which the surgeon tries to obtain a perfect
result with minimal consideration or mention of revisional
surgery. However, by their very nature, the results of both
procedures are not permanent, and changes in the shape
and symmetry of the breasts occur over time. This is
related to changes in the relationship of the breast
parenchymal volume and overlying skin envelope that are
most commonly due to significant fluctuations in weight,
pregnancy, and lactation, all of which alter the dynamics of
the breast volume–skin envelope relationship. However,
additional important factors include the individual
patient’s heredity, aging, and the inexorable influence of
gravity. Changes in breast shape following breast reduc-
tion are common, as is the development of asymmetry,
even when a symmetric, well-shaped breast appearance is
noted after the original surgery.1
Reoperative surgery following mastopexy or breast
reduction may be sought by the patient and undertaken to
address changes in the aesthetic appearance of the breast
that occur with the passage of time or to treat complica-
tions or problems resulting from the primary operation.
Unusual types of reoperative surgery in this setting are
sometimes necessary to treat an unexpected intervening
problem such as an occult malignancy discovered during
initial procedure or to treat recurrent breast enlargement
that can occur in the setting of virginal breast hypertrophy.2
As with every type of reoperative surgical procedure, an
understanding of the problem and the timing of the surgical
intervention are crucial. Whether the surgeon is operating
to treat a problem in his or her own patient or in a patient
previously operated on elsewhere, taking a careful history
and performing a physical examination are required.
Particular attention is paid to the patient’s chief com-
plaint. I need to understand what she is most bothered by.
I attempt to have her focus her complaint as much as pos-
sible. Is the patient dissatisfied with the scars, changes in
shape, contour problems, nipple malposition or frank
asymmetry, fat necrosis, or pain in her breasts? Following
a previous breast reduction, has there been overreduction
or underreduction with the persistence of symptoms? Or,
after a mastopexy, has the patient experienced a recur-
rence of her ptosis, or is she discontented with the loss of
upper pole fullness? A key element in successful revision
surgery lies in understanding what the patient is most con-
cerned with and what she would like you to do to help her.
ANATOMIC CONSIDERATIONS
Another key element is a precise understanding of the pre-
vious surgical procedure(s). This goes well beyond recog-
nizing the scar pattern and analyzing breast dimensions
and the relationship of the nipple to the breast tissue. It is
essential for the surgeon to understand the existing
source(s) of blood supply to the NAC. Any surgical proce-
dure on the breast parenchyma not only alters its architec-
ture but very often its blood supply as well. For example,
I believe that if a superior pedicle mammoplasty was per-
formed initially, then an attempt to base the blood supply to
the NAC using an inferior pedicle design may result in vas-
cular compromise of the NAC and possible nipple necrosis.
The sources of blood supply to the breast tissue emanate
from various pedicle systems3 (Fig. 5-1): the internal and
external mammary systems, the thoracoacromial artery with
perforators from the pectoralis major muscle (PMM), and the
intercostal vessels. An inferior pedicle procedure diminishes
the circulation from the internal and external mammary sys-
tems, and the surgeon must be aware of this. Because of this I
advocate performing revision surgery following both breast
reduction and mastopexy by using the same pedicle that was
employed during the first procedure. As mentioned in
Chapter 2 (see Fig. 2-42) and Chapter 3 (see Fig. 3-10), the
presence of an implant in the subglandular position reduces
the blood supply from the PMM perforating vessels and some-
times also from both the internal mammary and lateral tho-
racic systems. This must be borne in mind by the surgeon
considering a significant transposition of the NAC at the time
of revision of an augmentation mastopexy following a previ-
ous subglandular breast augmentation.
Another pertinent anatomic structure is the sensory
nerves to the nipple. Nipple sensation is primarily derived
from the fourth medial and lateral intercostal nerve, with
the anterolateral branch of the fourth intercostal nerve
thought of as playing the key role in providing sensation to
the nipple.1,4 Recently my experience with vertical mammo-
plasty using the medial dermoglandular pedicle has high-
lighted the significant contribution from the medial
branches of the intercostal nerves in terms of their contribu-
tion to the sensation of the breast skin and NAC (Fig. 5-2).
Any breast procedure that involves incising through
breast parenchyma or a significant resection of the breast
tissue adjacent to the central pedicle poses risk to the sen-
sory nerves. Laterally the sensory nerves have their course
just on top of the serratus fascia after perforating through
the serratus anterior muscle in the midaxillary line.3
Therefore it is important to stay in a plane above the ser-
ratus anterior muscle fascia when dissecting in this infe-
rior lateral breast region. As the nerves head in a medial
direction they run obliquely and take a superficial course
through the breast parenchyma as they proceed toward
the nipple. In general these nerves run with small arteries
and can be spared in many types of procedures.
PREOPERATIVE EXAMINATION
As previously discussed, the breasts must always be care-
fully and systematically evaluated in every patient. This
includes a detailed visual analysis and thorough palpation.

Chapter 5
Revision Surgery Following Breast Reduction and Mastopexy
185
The visual inspection is performed to evaluate the
shape, symmetry, contours, scar location, and skin quality,
along with nipple areola shape and position relative to
both the inframammary (IM) fold and breast volume in
the upright position. Careful notes are made regarding
symmetry of contour, nipple areola position, presence of
striae, overall skin quality, and position of scars.
Additionally, the presence, size, and location of contour
deformities are recorded.
I take photographs cropped in a uniform way of all
patients using the same background color and lighting
conditions. The views taken in each patient are the antero-
posterior (AP), each lateral, and each oblique. If there are
specific areas of interest in the consultation that may be
better highlighted by other views, I will take a photograph
from above and perhaps a view from below with the
patient lying supine on the examination table.
In addition I record the surface measurements of
breast structures from key fixed anatomic points and
record these on a worksheet in the patient’s chart. These
include the suprasternal notch (SSN) to nipple distance,
the breast base width, and the distance of the nipple from
the IM fold and from the midline. I refer to both diagrams
and photographs when planning all surgical procedures
on the breast.
anterlateral
intercostal N.
antermedial N.
intercostal nerve IV
Nipple Areola Innervation
FIGURE 5-1. Arterial blood supply to the breast. There are major contributions from the internal
mammary, the lateral thoracic, the intercostals, and the thoracoacromial system.
FIGURE 5-2. The nerve supply to the NAC is derived from the
medial and lateral braches of the fourth intercostal nerves.

186
Reoperative Plastic Surgery of the Breast
A tactile examination of the breasts includes careful
palpation of the skin, scars, and breast parenchyma. Of
course careful palpation is done to examine for any
masses, areas of thickening, tenderness, and scar adher-
ence. In general, reoperative surgical procedures should
not be undertaken until there is a return of mobility to the
breast tissue over the underlying chest wall structures, the
skin has reacquired its mobility over the breast
parenchyma, and the skin scars have begun to soften.
Breast palpation and tactile assessment also provide
additional insight into the elasticity of the skin, as well as
the volume, distribution, position, and elasticity of the
parenchyma. In every patient being evaluated for primary
and reoperative mastopexy I simulate the superior trans-
position of the breast parenchyma by pinching the lower
pole or lateral inferior pole of the breast mound. This
maneuver (Fig. 5-3A,B) provides additional insight into
the parenchymal elasticity and helps me to select the
appropriate technique for the mastopexy. The ability to
transpose the parenchyma to the upper pole of the breast
indicates good tissue elasticity and that the patient is
probably a good candidate for a vertical mastopexy. On
the other hand, if you are not able to produce this change
in breast shape with the maneuver described, a mastopexy
with both a vertical and horizontal skin excision should be
undertaken. In addition, such a patient should be
informed about an increased tendency for recurrent
mammary ptosis.
Mammographic examinations of the breasts are
ordered as necessary. If a patient seeking a reoperative
procedure has not had a mammogram and is near 35
years of age, I routinely order this study, even if the palpa-
tion examination of the breasts is normal. This mammo-
gram will serve as the baseline study for future
mammograms, and it will provide insight into any mam-
mographic alterations produced by the previous proce-
dures. Surgery on the breast parenchyma produces a
change in the breast tissue from the standpoint of intra-
parenchymal scars that are often discernible on the mam-
mogram. In addition, a patient with high adipose content
in her breasts who has had previous surgery may also
have calcifications in her breasts. These calcifications are
FIGURE 5-3. A, This 43-year-old patient will undergo a right vertical mastopexy at the time of an
immediate left breast reconstruction with a TRAM flap after a skin-sparing mastectomy done through a
vertical skin-sparing incision pattern. B, The pinch maneuver done in the lower pole evaluates the tis-
sue elasticity and ability to transpose the breast volume to the upper pole of the breast. She is a good
candidate for a vertical mastopexy procedure.

usually easily distinguishable from the worrisome calcifi-
cations that may be associated with mitotic processes in
the breast (breast cancers).
GENERAL COMMENTS REGARDING
REOPERATIVE BREAST REDUCTION
It is often stated that breast reduction patients are per-
haps the happiest patients in a plastic surgeon’s practice.
In the vast majority of instances these procedures result
in smaller, shapelier breasts that have a more youthful
appearance, albeit with scars on them. The tradeoff that
the breast reduction patient makes is “scars for shape.” In
my experience these patients gladly make this trade
because the resulting smaller breast size allows them to
perform virtually all of their activities of daily living more
comfortably. In my experience, the overwhelming major-
ity (>95%) of patients demonstrate a relief of their macro-
mastia-related symptoms. This has been borne out in the
plastic surgery literature by numerous outcome stud-
ies.5,6 It has been my experience that the vast majority of
breast reduction patients are happy with their surgical
outcome and they both accept and overlook the imperfec-
tions resulting from the breast reduction procedure,
including asymmetries and associated scar deformities.
I have found that, although there are numerous com-
plications that can occur following breast reduction, it is
rare for the surgeon to perform additional surgery to treat
a complication in the acute or subacute phases of wound
healing. I often say to patients seen for an initial consulta-
tion for macromastia symptoms that complications in
breast reduction are not all that common, and when they
do occur they usually heal without additional surgery. I
still believe that this is true. However, breast reduction
remains a highly litigated procedure,7 and therefore it is
important for the surgeon to review in detail the immedi-
ate and long-term potential risks of the procedure with
each patient. I do this by discussing with the patient the
risks that are enumerated on a preprinted consent form
(Fig. 5-4) that outlines the probable complications and
answering any questions the patient may have.
In the setting of reoperative surgery following a previ-
ous breast reduction, the initial consultation is longer in
duration than it is for other procedures, and follow-up
consultations are far more common. I want the patient to
understand that the risk of complications is greater than it
is in the primary procedure. There may be increased risks
for sensory loss in the NAC, increased scar tissue within
the breast, and more difficulty maintaining shape. Scars
cannot be erased, and skin healing can be less predictable
than it is with other procedures. Although improvement in
breast appearance is likely, no guarantees can be made.
Finally, a brief mention must be made regarding pain fol-
lowing the previous surgery. The etiology of breast pain, or
mastodynia, is multifactorial. I strongly believe that it is
rarely possible to cure pain with a scalpel. I specifically
mention this to patients who present with pain as one of
their main complaints by telling them that in no way can I
guarantee pain relief with this surgical procedure and that,
in fact, there is a chance that the pain could be worse.
In my practice the reoperation rate following breast
reduction is very low. Nevertheless, revisional surgical pro-
cedures are done in the setting of a previous breast reduc-
tion for an aesthetic compromise in breast appearance or
to treat problems resulting from the previous surgery.
Classification of the complications of breast reduction
and how I handle these complications follows.
Complications of Breast Reduction
See Table 5-1.
HEMATOMA
Hematoma can occur following any surgical procedure. The
presenting symptoms are acute swelling; tenderness; asym-
metry; ecchymosis; and, most prominently, pain. Pain is the
symptom that predominates when a hematoma occurs any-
where in the body.
The incidence of hematoma following breast reduction
is low (1% to 2%) despite the extensive infraparenchymal
dissection. In our practice the importance of refraining
from aspirin products for at least 10 days before surgery is
communicated to each patient. The patient’s ingesting
even a single aspirin during the week before the procedure
will cause me to postpone the procedure.
Drains do not prevent hematoma and are not used in
the majority of patients. However, I selectively use drains
in patients with large amounts of dense white parenchy-
mal tissue that exhibits a tendency to ooze. When incised
this stromal tissue inhibits contraction of the small blood
vessels, which results in prolonged oozing. In addition,
patients who undergo large resections (>1,000 g) after
which the parenchyma may not precisely fit the skin enve-
lope often benefit from the use of a drain.
Large hematomas recognized following surgery should
be drained. The most effective way of doing this is by
returning the patient to the operating room, opening the
incision, and placing a Jackson-Pratt drain (Ethicon, Inc.,
Somerville, NJ). I have found this to be the most reliable
method of managing this problem and the most effective
and reliable method of managing problems with
hematoma (and seroma as well, although with seroma I
place a Penrose rather than a Jackson-Pratt drain).
Alternatively, smaller hematomas can be aspirated using
an 18-gauge needle following infiltration of the skin with
lidocaine (Xylocaine). This method is effective when such
collections of blood are noted later in the postoperative
Chapter 5
Revision Surgery Following Breast Reduction and Mastopexy
187

188
Reoperative Plastic Surgery of the Breast
FIGURE 5-4. Sample consent form that I use for breast reduction.

Chapter 5
Revision Surgery Following Breast Reduction and Mastopexy
189
period (7 or more days following surgery) when the blood
begins to liquefy. I used this technique in this patient, who
had an inferior pedicle breast reduction for symptomatic
macromastia (Fig. 5-5A). She developed a localized collec-
tion of blood in the inferior medial aspect of her breast
reduction wound that was aspirated on postoperative day
10 (Fig. 5-5B). Subsequently she healed uneventfully and
shows an excellent result at 1 year postoperative without
excess firmness or other problem with her right breast
(Fig. 5-5C). Aspiration of a hematoma was also used in this
patient who had the diagnosis of hematoma made in the
lateral aspect of the wound following an inferior pedicle
breast reduction (Fig. 5-5D). She had very large breasts pre-
operatively with a wide chest. Patients with this body habi-
tus invariably have a large fold of tissue extending down
from their axillary region that is not part of their breasts
(Fig. 5-5E). I routinely tell such patients that I cannot
remove this fullness without extending the incision consid-
erably posteriorly. Furthermore, to do so can put the lateral
skin flap in jeopardy from the standpoint of its vascular
supply because additional vascularity is sacrificed and the
length-to-width ratio is increased. However, because this
patient was particularly bothered by the fullness, a more
aggressive surgical removal of tissue in this area with Mayo
scissors was carried out. No drain was placed. She devel-
oped a hematoma under the lateral chest flap that was aspi-
rated on postoperative day 7 in the office (Fig. 5-5F). A
second aspiration was needed 1 week later to successfully
resolve this situation. Not uncommonly more than one
aspiration is required. I also have patients apply pressure to
such areas with an Ace bandage (Becton Dickinson,
Franklin Lakes, NJ) that is applied and reapplied several
times during the course of the day.
SKIN FLAP ISCHEMIA AND SKIN LOSS
Breast reduction requires careful planning in terms of
flap design, surgical precision in terms of flap eleva-
tion, and pedicle resection. Enough tissue must be
resected from the pedicle such that the wounds are
approximated without excess tension in the line of
wound closure. When using the Wise pattern with its
inverted T incisional closure, the point of maximal ten-
sion is at the T junction. This pattern of flap closure
involves the development of skin flaps and draping of
these around a centrally positioned pedicle. For this
reason the sum of the measured lengths of the medial
and lateral skin flaps is always longer than the length of
the IM incision.
The lateral flap in an inverted T design tends to have a
longer length-to-width ratio, i.e., the blood supply is fur-
ther from the distal edge than it is from the edge of the
medial flap. For this reason, the lateral flap is more
prone to ischemia at its margin (Fig. 5-6). Such relative
skin flap ischemia can result in necrosis and full-thick-
ness skin loss if these flaps are closed under excessive
tension.
By the very nature of this flap design (Wise pattern or
inverted T) for breast reduction (and in fact for all
designs), the skin flaps are sutured with some tightness at
the line of closure. However, I do not believe that the skin
closure contributes significantly to breast shape. On the
contrary, I feel that the key element in this regard is pedi-
cle configuration. I believe that part of the art of breast
reduction is that the remaining pedicle must precisely fit
the wound created by the flap dissection (Fig. 5-7).
Therefore, if there is excessive tension in the line of clo-
sure, resection of additional parenchymal tissue from the
pedicle should be considered.
Ischemia of the skin flap edges is usually noted early in
the postoperative period. It is rarely noted on the operat-
ing table. In my experience, ischemia of the skin flap
edges following breast reduction is much more common
in patients who smoke. This is also true for the complica-
tions of delayed wound healing and fat necrosis and
should be mentioned to all prospective patients who are
smokers.
TABLE 5-1 Complications of Breast Reduction
Acute Complications
Subacute Complications
Long-Term Complications
Hematoma, seroma
Asymmetry
Contour deformities
Skin loss
Hypertrophic scars
Recurrent ptosis
Wound separation
Fat necrosis
Scar deformities/unfavorable scars
Cellulitis
Loss of shape
Nipple areola
Nipple malposition
ischemia
Underresection
Overresection

190
Reoperative Plastic Surgery of the Breast
FIGURE 5-5. A, Patient with symptomatic bilateral macromastia who will undergo an inferior pedicle
breast reduction. B, On postoperative day 7 she has a localized hematoma in the inferior medial aspect
of her breast aspirated. C, She shows an excellent cosmetic result with no adverse sequelae from the
hematoma. D, Breast reduction planned in patient who is obese, with large body habitus and large
breasts. (continued)