Reoperative Plastic Surgery of the Breast

242
Reoperative Plastic Surgery of the Breast
SELECTING THE RIGHT DEVICE
Begin with the end in mind.
As outlined in Chapter 2 and Chapter 3, Fig. 3-1A, there are
many implant options for the surgeon to choose from.
Good results in a given patient can be obtained from using
any number of implants. Surgeons tend to use implants
(and tissue expanders) they are experienced and comfort-
able with from the standpoint of predictably producing
good results in their hands. Different implants may be
used in different situations. Variability in patient
anatomy, including chest wall configuration, skin condi-
tions, and tissue deficits, may encourage the surgeon to
select a certain implant over another in a given situation.
There are very few ironclad rules or stipulations
regarding the choice of an implant for breast reconstruc-
tion. As noted in Chapters 2 and 3, the implant selected
should have the appropriate base width, volume, and ver-
tical dimension to produce the desired contour and shape
in the reconstructed breast. The analysis of the curves,
shape, and relationship of the opposite breast to the chest
wall is reviewed in Chapter 2.
Following a thorough discussion with the particular
patient about her goals and a careful examination of the
breasts, the surgeon must be able to envision what he or she
is trying to create and then select the appropriate implant(s)
for that situation. Presently in my practice implant recon-
struction is almost always (>98% of the time) done in stages,
with the placement of a tissue expander as the first stage,
followed some time later by the placement of an implant.
Therefore it is important for me to select the appropriate tis-
sue expander, as well as the appropriate implant.
FIGURE 6-5. (CONTINUED) This vertical mastopexy tech-
nique produces an almost implantlike fullness in upper pole that
markedly enhances breast symmetry (D–E). Patient is shown 11
months following surgery.

BEGIN WITH THE END IN MIND
Selection of the tissue expander for a given patient starts
with selection of the implant(s). The choice of implant for
breast reconstruction is largely determined by the base
width of the breast, by the desired breast volume, to some
degree by the vertical height of the breast, and by whether
the patient chooses to have a contralateral breast augmen-
tation. After the evaluation is complete, I find that it is
helpful to refer to the implant charts compiled by each of
the implant manufacturers (see Fig. 3-5) for the final
implant selection. The surgeon must pick a tissue
expander that will accommodate the base width of the
implant that will be used. Therefore, I try to always select
the implant I will use before I place the expander.
In most cases the choice comes down to either of two
expanders, with one having a slightly larger base width
than the other (e.g., a 12-cm versus a 13-cm expander). In
most cases I choose the larger device for a variety of rea-
sons. A larger space will allow better movement of the
implant within the periprosthetic capsular space because
my preference is to use a smooth-walled implant.
Additionally, if the periprosthetic space is of slightly larger
dimension than the selected implant, it can be reduced in
volume and altered in its dimension or changed in its
position (e.g., to a lower level) in a fairly precise way by a
suture capsulorrhaphy or direct excision of the capsule
with surgical repair. This is especially common if the
patient elects to undergo contralateral breast augmenta-
tion because the larger expander will accommodate the
larger implant needed on the side of the reconstruction to
produce volume symmetry with the augmented opposite
breast.
I have found that the best appearance of the recon-
structed breast is achieved when there is little or no
manipulation of the lower portion of the periprosthetic
capsule because this is the area that accounts for the
smooth appearance of the IM fold and lower pole of the
reconstructed breast. However, in most cases the volume
and internal dimensions of the periprosthetic capsular
space can be increased by performing appropriately
positioned capsulotomies. In this way progressively
larger implants can be accommodated in a given
periprosthetic capsular space that has been created by
the tissue expander. This is commonly done at the time
of exchange of the tissue expander for the implant that
will be used for the breast reconstruction. Similarly, the
volume of the periprosthetic space can be decreased by
performing the necessary capsulorrhaphy(ies) before
implant placement.
In summary, when performing implant-based breast
reconstruction, choose the implant first. This entails
selecting a device of sufficient base width, height, and vol-
ume to produce the appearance of visual symmetry with
the opposite breast when viewed in the frontal position.
For implant breast reconstruction (and breast augmenta-
tion to a great degree), device selection is governed by
dimensional concepts8 (Chapters 2 and 3). This is espe-
cially true when using saline-filled implants. The volume
contained in these breast implants can vary depending on
projection or profile of the device, i.e., a high-profile
implant contains a greater volume of filler for a given base
dimension (diameter) of the implant.
The implant selection for a given patient is determined
by the factors previously reviewed, the most important of
which is the base dimension of the opposite breast. The
fill volume and projection are also important. Different
volumes are contained within a given base diameter of an
implant depending on its projection specifications. These
specifications are listed on the charts issued by the
implant manufacturers (see Fig. 3-5). Selection of the tis-
sue expander is then made to create a periprosthetic cap-
sular space that will accommodate this implant.
PREOPERATIVE PATIENT ASSESSMENT
I now believe that for breast reconstruction, tissue expan-
sion is more of a tissue-molding process than it is a
process of tissue expansion or skin stretching per se. That
is to say, I believe that the results of the tissue expansion
process in many ways represent more of a loan than a div-
idend. For that reason, I believe that when the measured
or anticipated skin tissue deficiency in a given patient is
more than 4 cm, this is an indication for a flap reconstruc-
tion rather than a tissue expander insertion. That said, the
majority of breast reconstructions in my practice are done
in stages by first creating a periprosthetic capsular space
by shaping and molding the tissues in the lower pole of
the new breast, then placing the implant.
As noted several times earlier in this chapter, when tis-
sue expansion is chosen, the surgeon must select a tissue
expander with the appropriate base width for a given
patient. This dimension is determined by measuring the
base width of the patient’s opposite breast from the
parasternal area to the anterior axillary line in the frontal
plane [anteroposterior (AP) view; Fig. 6-6]. This can be
done using a caliper or tape measure.
The height or superior extent of the opposite breast is
also noted. It is the most important dimension for select-
ing the implant that will be used to complete the second
stage of the reconstruction. This dimension is most accu-
rately determined by gently displacing the opposite breast
posteriorly against the chest wall with the ulnar side of the
examiner’s hand (Fig. 6-7) and noting the superior extent
of the breast fullness. I usually outline the dimensions
with dots placed on the skin (Fig. 6-7). This vertical
dimension from the dots to the lower contour of the
breast is recorded in the chart for each patient because it
serves as a guide for the selection of the implant.
Chapter 6
Revision of Implant Breast Reconstruction
243

This vertical dimension is not nearly as important for
selecting a tissue expander as it is for selecting the implant.
I now almost exclusively use a low-height tissue expander
(Fig. 6-8). However, I record the breast height in the
patient’s chart and refer to it before I select the implant.
Suffice it to say that the key dimension in selecting a tissue
expander is the base width of the contralateral breast (see
Fig. 2-3). Initial tissue expander positioning is important
in that a very accurate placement of a tissue expander sets
the stage for the best possible result in terms of permanent
implant position and breast appearance.
Currently available tissue expanders for breast recon-
struction include single-chamber saline devices (Figs.
6-8A,B and 6-9), dual-chamber saline devices (PMT), and
combination saline–silicone devices [e.g., Becker (Mentor
Corp., Santa Barbara, Calif)]. For breast reconstruction
procedures, virtually all expanders are textured devices.
Most have integrated ports, but some, such as the Becker
expander/implant and the Spectrum (Mentor Corp., Santa
Barbara, Calif) (Fig. 6-10), have remote fill ports.
As stated, when planning a breast reconstruction I always
“begin with the end in mind” from the standpoint of
selecting an implant. In the United States both manufac-
turers (Mentor Corp. and INAMED Medical, Santa
Barbara, Calif) offer a wide variety of implant shapes, pro-
jection profiles, and surface characteristics, along with
brochures and charts I refer to constantly when dimen-
sionally planning an implant reconstruction (see Fig. 3-5).
Both silicone gel and saline-filled implants are used in my
practice, but the distinct majority of my breast recon-
struction patients request the silicone gel–filled breast
implant. The cohesive gel implant is gaining wide popu-
larity in Europe and South America. My early experience
with that device has been a very positive one from the
standpoint of breast shape.
As stated, each surgeon has his or her own prefer-
ences in terms of implants for breast reconstruction. I
feel that I am currently achieving the most consistently
good results with the use of a high-profile smooth-walled
silicone gel implant placed after the first-stage tissue
expansion is completed with a low-height tissue
expander. As noted in Chapter 3, I am big believer in
implant displacement exercises as a means of promoting
implant (and breast) softness. Therefore I have all
patients who receive smooth implants for breast recon-
struction (as well as for breast augmentation) perform
implant displacement exercises twice a day—forever. I
believe this is helpful following the placement of a
smooth-walled high-profile gel implant, and it seems to
promote better mobility of the implant in the peripros-
thetic capsular space.
I have extensive experience with textured shaped
implants of both the saline-filled and silicone gel–filled
types. Patients with long torsos and who require upper
pole fullness are well served by tall implants such as the
244
Reoperative Plastic Surgery of the Breast
FIGURE 6-6. Measurement of base dimension of opposite
breast serves as guide to selection of appropriate implant and,
before that, correct tissue expander for breast reconstruction.
FIGURE 6-7. Superior extent of upper pole of patient’s breast
tissue is noted following gentle displacement of breast posteri-
orly against the chest wall. This is outlined by dots placed on the
skin. This maneuver will help guide selection of an implant with
appropriate dimensions for breast reconstruction.

Chapter 6
Revision of Implant Breast Reconstruction
245
INAMED Style 468 saline implant or the INAMED Style
410 textured shaped cohesive silicone gel device. My best
results with saline implants with a wide variety of patient
body types have come from the use of a shorter vertical
dimension implant, namely the INAMED Style 363LF and
the Contour Profile shaped textured saline device devel-
oped and marketed by Mentor Corp.
With experience, good results can be obtained using
almost any implant. At present my most consistent results
are obtained with the use of a smooth-walled high-profile
silicone gel–filled implant following preliminary tissue
expansion with the short height tissue expander. I inform
each patient before surgery that a breast reconstructed
with an implant will not fill the anterior (front part) of her
bra cup like her normal breast does. Furthermore, I tell
patients preparing to undergo implant breast reconstruc-
tion that breasts that are reconstructed with implants will
not look like, move like, or feel like their normal breasts.
FIGURE 6-8. Breast tissue expanders with textured surface
and integrated filler valves. Photographs of low-height tissue
expanders. A, Mentor style 6200. B, On face view of INAMED
(McGhan) style 133 LV. C, Lateral view with fluid in device.
FIGURE 6-9. Tissue expanders come in various dimensions in
terms of base width and height.
FIGURE 6-10. Becker expander/implant (Mentor Corp.) with
inner chamber of saline and outer rim of silicone gel with sepa-
rate filling port, and Spectrum saline expander/implant (Mentor
Corp.), which is a pure saline device with remote filling port.

246
Reoperative Plastic Surgery of the Breast
DIFFICULT PATIENTS FOR IMPLANT-
BASED BREAST RECONSTRUCTION
Synthetic implant-based reconstruction is often the
default option for a patient who has insufficient donor tis-
sue for an autogenous reconstruction. These patients are
commonly of asthenic habitus and their chest wall tissues
are very often thin (Fig. 6-11A). This situation often sets
the stage for a suboptimal outcome following the tissue
expansion process because the expansion itself further
thins or attenuates the covering tissue (Fig. 6-11B). This
scenario permits any implant irregularities to show
through the skin (Fig. 6-11C,D). This type of patient must
be informed before surgery of the limitations imposed by
suboptimal qualitative and quantitative covering tissue at
the site of implant breast reconstruction. Patients who
have undergone previous lumpectomy and radiation or
radiation of the skin following a mastectomy are also sub-
optimal implant reconstruction candidates (Fig. 6-11E).
The radiated tissue does not expand easily (Fig. 6-11F),
and in my experience there is a high rate of capsular
contracture with the placement of any type of implant that
often results in an unsatisfactory breast reconstruction
(Fig. 6-11G). Finally, patients with a wide chest dimension,
husky build, and heavy tissue in the chest region are also
suboptimal candidates for implant reconstruction because
they seem to swallow up the implants (Fig. 6-11H,I) and
the tissue drape over the implants often fails to adequately
replicate the opposite breast silhouette.
In summary, an essential aspect of achieving good
aesthetic outcomes from implant-based breast recon-
struction is patient selection. All too often implants are
the default option. In such cases there are definite limita-
tions imposed by the tissue conditions, and this reality
must be communicated to the patient, preferably before
surgery.
FIGURE 6-11. A, Preoperative AP view of very thin patient
requiring bilateral mastectomy who is interested in immediate
breast reconstruction. B, Appearance following completion of
expansion with full-height tissue expander device. C, AP view
following saline implant placement shows folds in superior
medial breast. (continued)

Chapter 6
Revision of Implant Breast Reconstruction
247
FIGURE 6-11. (CONTINUED) D, Oblique view. Note folds in superior medial aspect of right breast
and superior aspect of left breast. These may have been minimized by use of a low-height tissue
expander, which minimizes attenuation of upper pole breast tissues. E, Postlumpectomy deformity in
diabetic patient with recurrent breast cancer who requests reconstruction with an implant. F, Low-
height issue expander is in place but radiated tissue envelope does not expand easily over 9 months. G,
Placement of saline implant produces smaller, immobile breast form that shows advanced degree of
capsular contracture. (continued)

FIGURE 6-11. (CONTINUED) H, Preoperative AP view of patient requiring left mastectomy who
requests an implant-based immediate left breast reconstruction. Tissue expansion precedes placement
of large saline implant (14 cm, 650 cc). I, Final result is a breast that is a poor match for the large oppo-
site breast in this patient with a very wide chest dimension and thick covering tissues.
FIRST-STAGE BREAST
RECONSTRUCTION WITH TISSUE
EXPANSION USING SHORT-HEIGHT
TISSUE EXPANDERS
For a long time I have believed that perhaps the main prob-
lem with tissue expansion for breast reconstruction is that
too much stretching (and harmful tissue thinning) occurs
where you do not need it or want it, namely in the tissues of
the upper pole of the new breast. For that reason most
recently I have used tissue expanders that predominantly
[Contour Profile (Mentor Corp.); see Fig. 6-8A] or exclu-
sively [LV low-height crescent expander (McGhan Medical
Corp., Santa Barbara, Calif); see Fig. 6-8B] expand the
lower pole tissues. These devices provide expansion where
it is needed, i.e., predominantly in the lower pole. The tis-
sue expander produces the appearance of a shelf or a ledge
in the upper pole of the breast that is being created (Fig. 6-
12). There is an additional benefit of not stretching the
upper pole: a better breast shape at the second stage when
the expander is removed and the implant is inserted,
regardless of which implant is used. This is because the
pectoralis major muscle (PMM) has not been stretched,
and following the additional subpectoral dissection at the
second stage the muscle compresses the implant, produc-
ing a straighter contour or tapered shape in the lateral view.
When I use a short-height tissue expander, I employ
underexpansion. Specifically, I fill the expander to within
80% to 85% of the desired implant volume. This is
because approximately the upper 30% of the new breast
form is not generated as part of the expansion process,
and the implant selected will generally have a volume that
is 20% to 30% greater than that contained in the expander
FIGURE 6-12. Typical appearance of a patient at completion
of tissue expansion process when a low-height tissue expander is
used. Note shelflike appearance at superior aspect of expander.
A, AP view. B, Lateral view.

Chapter 6
Revision of Implant Breast Reconstruction
249
at the completion of the filling process. I then give the tis-
sues time to accommodate to their degree of stretch or
expansion by allowing 8 to 12 weeks to elapse between the
last expansion and the date of the implant exchange.
At the time of tissue expander removal, a superior cap-
sulotomy (Fig. 6-13A) is always needed if a short-height tis-
sue expander has been used. This capsulotomy allows the
surgeon to open and precisely develop the submuscular
plane in the upper breast area, which has not undergone
expansion (Fig. 6-13B). This allows the surgeon to create
the desired fullness and shape of the upper pole by employ-
ing modifications of the surgical dissection in conjunction
with the implant diameter, volume, and projection. If cor-
rections of the IM fold or medial or lateral contours (Fig. 6-
14) are needed after the expansion, these are done while
performing the superior capsule release or capsulotomy.
In a very real sense this type of tissue expander permits
the surgeon to control the upper pole shape of the newly
reconstructed breast in a way not possible with other tis-
sue expander designs. This is why it has been my
FIGURE 6-13. A, Outline for superior capsulotomies that will
be performed at the time of low-height tissue expander removal
and implant placement. B, Development of subpectoral plane in
upper breast area performed to precisely accommodate place-
ment of selected implant. C, Appearance of breast 6 months fol-
lowing placement of smooth-walled high-profile silicone gel
implants.

preferred method of tissue expansion for the vast majority
of patients undergoing tissue expander breast reconstruc-
tions over the past 3 years. In my opinion it has increased
the artistry and made this type of reconstruction more fun
and fulfilling for both the patient and the surgeon.
I find it helpful to have sample tissue expanders and
implants in the office for patients to examine. I also have
schematic diagrams available so that patients can gain an
insight into how the implant is to be positioned while they
examine the integrated filler value and understand how it
is filled. In addition, I find that it is helpful to show
patients several samples of the type of implant that is
most likely to be placed following the completion of the
expansion process.
I believe that the technique used to place the tissue
expander is very important. The device should be placed
such that the lower pole accurately simulates the IM fold
level of the opposite breast, and it should be placed in
such a way that maximum skin recruitment and stretch-
ing (as opposed to muscle stretching) in the lower pole
routinely occurs. Selecting an expander with the appro-
priate base dimension establishes the correct horizontal
dimension of the periprosthetic capsular space and hence
the correct horizontal silhouette of the new breast form.
In this way the expansion process can shape and mold the
surrounding soft tissue. Accurate device placement allows
the tissue expansion process to generate a custom-made
periprosthetic capsular space. This allows the preopera-
tively selected implant to be positioned in such a way to
achieve the optimal breast shape.
The accuracy of the initial expander placement (at the
first stage of the reconstruction) greatly facilitates a satis-
factory outcome for most tissue expander/implant breast
reconstructions. For that reason I will now describe my
approach to the placement of a tissue expander in the set-
ting of immediate breast reconstruction and also in the
setting of a delayed breast reconstruction.
TECHNIQUE OF TISSUE EXPANDER
PLACEMENT—IMMEDIATE
RECONSTRUCTION
One of the most important factors in obtaining consistently
good results with tissue expander breast reconstruction is
maximizing the soft tissue coverage for the device. For me,
this means the upper part of the expander (below the inci-
sion) is covered by the PMM and the lateral portion of the
expander is covered by the serratus anterior muscle slips.
The lower part of the device sits below the deep layer of the
adipose tissue beneath an incision in the rectus abdominis
muscle fascia medially and in the lateral two thirds of the
IM fold just deep to the divided external oblique muscle
(Fig. 6-15). This positioning is achieved in most cases of
immediate breast reconstruction in the following way.
The marking for tissue expander insertion is straight-
forward. A skin-sparing mastectomy is preferred and per-
formed in virtually every case. At our center the marks for
the skin resection are designed by the plastic surgeon, but
they are confirmed as oncologically sound by the surgeon
performing the mastectomy. The most important land-
mark is the IM fold (Fig. 6-16). The lower limit of the dis-
section is either to the existing fold or to some level
beneath it if the existing fold is too high relative to the
opposite breast. The medial extent of the dissection is to
the parasternal perforating vessels arising from the inter-
nal mammary artery. Laterally the dissection conducted
in a plane below the serratus anterior muscle is usually
performed to a site just posterior to the anterior axillary
line. It can be extended as far posteriorly as the midaxil-
lary line, however, if this is needed to accommodate the
chosen expander. The plane above the ribs and beneath
the serratus muscle over the lateral chest is quite distinct
and easy to develop under direct vision. The necessary
pocket dissection is dependent on the dimensions of the
opposite breast when measured from the parasternal area
250
Reoperative Plastic Surgery of the Breast
FIGURE 6-14. Additional modifications of capsule are out-
lined before surgery in two different patients. Such capsular
modifications are very common and are completed at the time of
expander removal, along with superior capsulotomy (Fig. 6-13B)
and subpectoral dissection (Fig. 6-13C).

Chapter 6
Revision of Implant Breast Reconstruction
251
to the anterior axillary line, and it is developed to accom-
modate the selected tissue expander. The dissected space
should be slightly larger than the height and width dimen-
sions of the selected tissue expander.
This dissection is done with the electrocautery device
using the coagulation mode under illumination with a
headlight or lighted retractor. The dissection proceeds
inferiorly below the rectus abdominis muscle fascia. In
immediate reconstruction it is imperative for the plastic
surgeon to convey to the general surgeon performing the
mastectomy the importance of not violating the pectoralis
fascia in the lower aspect of the mastectomy dissection
near its confluence with rectus fascia. In addition, the tis-
sue between the PMM fascia and the rectus fascia, which I
call the fascia intermedialis (see Fig. 6-15), should not be
violated. If it is injured, it is very difficult to raise the rectus
fascia confluent with the PMM fascia. If the PMM muscle
is inadvertently injured or detached at its inferior origin, it
most often can be repaired and placed back to its point of
origin with 3-0 PDS suture (Ethicon, Inc., Somerville, NJ).
If it cannot be sutured to its origin, it is often possible to
suture it to the undersurface of the skin flap with 3-0 PDS
suture, thereby providing muscle coverage for the tissue
expander beneath the skin closure. Other surgeons have
used 3-0 Prolene suture (Ethicon, Inc., Somerville, NJ) tied
over a bolster to achieve the same goal of attaching the
divided origin of the PMM to the inferior skin flap.8
The subpectoral plane is accessed and developed by
splitting the PMM in line with its fibers 3 cm medial to its
lateral edge (Fig. 6-17A). The loose areolar layer beneath
the PMM is readily visualized and the dissection proceeds
medially, laterally, and superiorly. With the short-height
expander, it is generally not necessary to dissect the sub-
pectoral space beyond the third intercostal space.
During the initial dissection I find it easiest to identify
the plane beneath the rectus fascia by extending the
muscle-splitting incision in the PMM inferiorly over
and through the rectus fascia (Fig. 6-17B) by simply
proposed
inframammary
fold
Splitting fibers
in pectoralis muse
down to rectus fascia
thin
fascial
confluence
A
FIGURE 6-15. Frontal (A) and sagittal (B) views of tissue
expander position, which is covered by the PMM superiorly and
the slips of serratus muscle laterally and lies beneath the ante-
rior rectus abdominis fascia inferiorly with its lower pole above
the fascia but beneath the deep adipose layer.
FIGURE 6-16. Marking patient for tissue expander insertion.
The most important mark is the level of the IM fold. This patient
will undergo a skin-sparing mastectomy.

continuing it inferior-medially over and through the rec-
tus fascia. When developing the plane deep to the PMM
inferiorly, the medial PMM is elevated with the medial
rectus muscle fascia. The lateral PMM is elevated in con-
tinuity with the lateral rectus fascia and accompanying
external oblique muscle. The subfascial plane above the
rectus muscle is developed in conjunction with the
subexternal oblique plane as the dissection is carried lat-
erally. Near the IM fold the plastic surgeon must gain
access to the plane of the deep adipose layer above the
rectus fascia by incising the fascia on its deep surface. At
the desired level for the new IM fold (marked on the skin
preoperatively) the dissection is brought more superfi-
cial, i.e., toward the skin. An incision is made with the
electrocautery directed superficially through the deep
surface of both the rectus fascia and external oblique
muscles until the yellow adipose tissue at the deep sur-
face of the deep layer of adipose tissue is seen (Fig. 6-18).
This enables the tissue expansion process to generate the
new IM fold in the most ideal position. Under direct
vision the rectus fascia and external oblique muscle is
incised on its deep surface in the shape of an arc that
outlines the desired shape of the IM fold. Along this
entire incision the surgeon will note a yellow layer of adi-
pose tissue, and he or she should stop the dissection
when this level is reached.
When this is completed, in addition to a line of yellow
adipose tissue, the surgeon will note markedly increased
distensibility of the entire inferior muscle–fascia envelope
in the area of the lower pole under the inferior skin flap as
the deep subcutaneous space is entered. It is in this plane
that the lower pole of the tissue expander is positioned. If
done properly there is complete coverage of the expander
by the muscle layer above and the lower skin flap, includ-
ing the rectus fascia and the external oblique muscle
below.
The only patients in whom I do not make a concerted
effort to release the rectus fascia and the external oblique
muscle in this way are patients with exceedingly thin tis-
sues, i.e., those patients with extremely little or virtually
no subcutaneous adipose tissue. In such patients the
external oblique muscle and rectus fascia are usually also
thin, but they may provide a little bit of extra covering tis-
sue or tissue padding, which may help camouflage the
inferior edge of the implant. For that reason I may not
extend the dissection superficially at the IM fold level in
these patients.
A barrier drape of OpSite (Smith & Nephew, Largo,
Fla; Chapter 3) is placed on the skin of the breast area and
an opening is cut in it to permit the passage of the selected
expander into the wound. In this way the tissue expander
does not make contact with the skin. The expander is
placed into position after the removal of the factory-
instilled air and without any fluid inside of it. As previ-
ously outlined, accurate positioning of the expander is
252
Reoperative Plastic Surgery of the Breast
FIGURE 6-17. A, Subpectoral plane is developed by splitting the
PMM in the direction of its fibers 3 cm medial to lateral edge of
PMM. B, Dissection is brought inferiorly to the level of the prox-
imal aspect of the anterior rectus fascia, which is seen as the
white layer in the inferior aspect of the wound just above the
retractor.

Chapter 6
Revision of Implant Breast Reconstruction
253
essential to facilitate symmetry. When it is in this flat-as-a-
pancake (see Fig. 6-8) state, I believe that the most accu-
rate positioning of the device is achieved. Next, sterile
saline is introduced through a closed filling system.
The head of the operating table is then brought as close
to 90 degrees as possible so that the symmetry of the IM
folds can be checked with the patient in the sitting posi-
tion. The levels of the IM folds must be as symmetric as
possible to facilitate overall breast symmetry. If such sym-
metry is not achieved, device repositioning or additional
dissection or a combination of these maneuvers is done to
achieve symmetric IM fold levels. As much fluid as possi-
ble is then placed into the expander while still permitting
a tension-free closure of the skin wound. Closure of the
PMM fibers ensures total deep tissue coverage of the
device beneath the level of the skin incision.
This method is used for tissue expander placement in
both immediate and delayed breast reconstruction. To
reiterate an important point, the release of external
oblique and rectus fascia places the lower pole of the tis-
sue expander in the deep subcutaneous adipose space
and this allows the expander to stretch and recruit skin
rather than muscle. In my opinion this makes the
process of tissue expansion for breast reconstruction
quicker and less painful. In addition, placing the
expander in the deep layer of adipose tissue allows the
creation of a well-defined, natural-appearing lower
breast pole.
Finally and most importantly, the use of short-height
expanders has led to focusing the expansion process
where it is needed—in the lower pole. In my experience
the combination of using the described technique of tis-
sue expander placement and the new short-height devices
has resulted in implant-based breast reconstructions with
a consistently better shape, marked by excellent lower
pole aesthetics and a tapered upper pole (Fig. 6-19).
FIGURE 6-18. A, As the surgeon is looking toward the patient’s foot and the retractors are spreading
the lateral and medial rectus muscle segments. An incision has been made in the rectus fascia directed
superficially toward the skin. Note yellow fat that has come into view. This is the deep surface of the
deep subcutaneous adipose tissue. B, The incision is continued laterally, dividing the external oblique
muscle, exposing the adipose tissue laterally, and establishing the position of the lower pole of the tissue
expander and of the IM fold.

FIGURE 6-19. Preoperative appearance of breasts on AP (A) and lateral (B) views before a bilateral
mastectomy and immediate breast reconstruction with low-height tissue expanders. Two-year postop-
erative appearance on AP (C) and oblique (D) views following placement of shaped textured silicone gel
implants with base width of 14 cm and gel volume of 540 cc.

Chapter 6
Revision of Implant Breast Reconstruction
255
SURGICAL TECHNIQUE—DELAYED
BREAST RECONSTRUCTION WITH
TISSUE EXPANDER PLACEMENT
Preoperative patient marking is performed in every case
exactly as described earlier. As in immediate reconstruc-
tion, the opposite breast serves as a template for the surgi-
cally absent breast in terms of IM fold level and base width
(see Fig. 6-7). Most often only the central 60% of the mas-
tectomy scar is incised and removed to permit exposure of
the underlying PMM. However, if the scar shows hypertro-
phy, evidence of step-off, or other irregularity, it is entirely
excised. Skin flaps are raised inferiorly and superiorly for a
distance of 3 cm to expose the PMM fibers. The dissection
of the subpectoral, subserratus space is then performed as
described earlier and inferiorly the deep subcutaneous
space (immediately superficial to the rectus fascia) is
accessed. The dissection in the setting of a previous mas-
tectomy is easier and generally proceeds more quickly
than the same dissection done at the time of a mastectomy.
This is because the scar tissue and healing following the
mastectomy makes injury to or avulsion of the PMM
exceedingly rare. In the case illustrated earlier (see Fig. 6-
7) the plan was for a silicone gel implant reconstruction of
the left postmastectomy defect with a partial subpectoral
silicone gel breast augmentation of the contralateral right
breast. A 12-cm base width tissue expander was used
because it would accommodate a 12-cm 375-cc silicone gel
implant on the left. (In addition, the plan called for a 160-
cc silicone gel implant on the right [Fig. 6-20A,B].) Those
implants were placed with the result displaying excellent
shape and symmetry of the breasts (Fig. 6-20C,D).
FIGURE 6-20. A, Delayed left breast reconstruction with an implant-based strategy. B, Low-height
tissue expander appearance at the end of tissue expansion process. The base width is adequate to
accommodate previously selected implants as depicted in the preoperative plan outlined on skin.
Postoperative result at 9 months in AP (C) and oblique (D) views.

ACUTE COMPLICATIONS FOLLOWING
TISSUE EXPANDER AND IMPLANT
PLACEMENT
The postoperative complications occurring in the acute
phase following tissue expander placement and implant
placement are bleeding, hematoma, seroma, infection,
skin loss, implant exposure, and loss of the device. In gen-
eral each of these should be managed aggressively to
prevent loss of the expander.
Hematoma
A collection of blood may occur in the submuscular or sub-
cutaneous space. The surgeon routinely obtains meticulous
hemostasis at the time of expander insertion. Despite this,
hematomas can occur. This condition is either the result of a
clot that comes off a blood vessel previously controlled at
surgery or from a diffuse oozing that may be seen after the
use of aspirin products. The former situation is more com-
mon and may occur following a cough or Valsalva maneuver.
The most likely source is a small arterial branch of the inter-
nal mammary, lateral thoracic, or intercostal system. The
patient usually presents with swelling, ecchymosis, and ten-
derness in the affected breast. I believe that returning the
patient to the operating room to evacuate the hematoma is
the best course. Most often a distinct bleeding point is not
found. Nevertheless, the blood should be evacuated and a
drain placed. This is the best chance of achieving a good
reconstruction with the lowest probability of capsular
contracture.
In addition, when a hematoma occurs in the subcuta-
neous space, it almost always imparts stiffness to the skin
flap due to the fibrosis that results in response to the pres-
ence and the biologic resorption process of the blood col-
lection in this space. Therefore in cases with significant
hematomas (Fig. 6-21) I believe in the conservative treat-
ment to reoperate to evacuate the blood and to place a
drain (Fig. 6-21B). In this way the surgeon creates the best
possible softness and draping potential of the skin flap
over the implant placed at the second stage.
Such a case is illustrated by this patient who presented
with swelling and ecchymosis of the left breast 1 week fol-
lowing an immediate tissue expansion reconstruction of
the left breast (Fig. 6-21A). She underwent operative
exploration and removal of blood from the subcutaneous
space (Fig. 6-21B). The tissue expander in the submuscu-
lar position had been completely covered by the PMM and
was preserved. She underwent successful bilateral tissue
expansion, and subsequent implant placement produced a
good outcome for her in terms of her bilateral breast
reconstruction (Fig. 6-21C). I believe blood around an
implant probably increases the risk of capsular contrac-
ture in the setting of both breast reconstruction and
breast augmentation. As also noted, the additional fibrosis
in the skin flap that often occurs in this setting limits the
optimal drape of the skin flap over the implant, thereby
limiting the aesthetic outcome. Therefore, it is my custom
to evacuate any significant collection that occurs.
Seroma
Seromas are not uncommon, especially following immedi-
ate breast reconstruction with tissue expander placement. It
is most likely due to the extensive dissection of the subcuta-
neous space during elevation of the mastectomy flaps or dur-
ing axillary dissection. Although a drain is placed into this
space in virtually all cases and some element of tamponade
is provided by the saline fill of the expander, seromas still
occur. They are usually managed by sterile needle aspiration
of the subcutaneous space with the needle being placed over
the area of the filler port of the expander but not being
advanced to the point where it penetrates the port (Fig. 6-
22A). The fluid can be compressed or moved to the area
immediately over the filler port by an assistant’s hand (Fig. 6-
22B). Following aspiration of the seroma fluid, saline is
installed into the expander to obliterate the space into which
it might reaccumulate. It may be necessary to perform this
sequence several times before the problem is resolved.
Seroma fluid sequestered laterally over the chest wall
or lateral aspect of the expander may represent a lymph
fistula. Such fluid accumulations are carefully aspirated
after protecting the expander or implant. Occasionally it
may be necessary to return the patient to surgery to con-
trol a lymphatic vessel or to place a drain.
A seroma may co-exist with an area of skin flap
ischemia or incipient wound separation. In such cases it is
best to return the patient to the operating room to drain
the seroma, resect the skin in question and perhaps
decrease the fluid amount in the expander, and then
reclose the wound over a suction drain.
This situation is illustrated by the following case (Fig. 6-
23A), where the patient was noted to have clear fluid
drainage from her left breast reconstruction incision follow-
ing the placement of a tissue expander. There were no local
or systemic signs of infection. She was returned to the oper-
ating room within 24 hours, where the fluid was drained,
the cavity was débrided with a uterine curette, and a drain
was introduced through a remote lateral incision (Fig. 6-
23B). Muscle coverage over the expander was re-established
and the edges of the skin wound were excised and reapprox-
imated. Her tissue expansion was completed (Fig. 6-23C),
and a satisfactory appearance of her breast reconstruction
resulted from the placement of an implant with a contralat-
eral vertical augmentation mastopexy (Fig. 6-23D). This
case illustrates that when serous fluid is persistently drain-
ing through the wound following an implant breast recon-
struction, exploration is indicated to minimize the chance
of implant loss. Excision of a seroma cavity and closure over
a drain can often prevent the loss of the implant.
256
Reoperative Plastic Surgery of the Breast

FIGURE 6-21. A, Hematoma following immediate left breast
reconstruction noted on postoperative day 5. B, Patient was
returned to operating room for drainage of this collection of
blood, which was located in the subcutaneous space. C, Patient
demonstrates a very satisfactory breast reconstruction seen
2 years following nipple areolar tattoo.
FIGURE 6-22. The safe method for aspirating a fluid collection (serosanguineous) anterior to the
muscle coverage over tissue expander used for breast reconstruction. A, Sterile needle is introduced
over filler port but not placed through it. B, Assistant can “milk” or compress tissue to move a lateral
seroma over site of port, where it can be safely aspirated.

258
Reoperative Plastic Surgery of the Breast
FIGURE 6-23. A, A 46-year-old patient shown preoperatively for immediate left breast reconstruction
with tissue expander placement. She developed serous drainage through the wound on postoperative
day 4 without signs of infection. B, She was immediately returned to operating room for exploration of
the wound. Seroma was drained and subcutaneous space was curetted and closed again over drains. C,
Tissue expander was salvaged. D, Placement of silicone gel implant produced very satisfactory recon-
struction of left breast.

Chapter 6
Revision of Implant Breast Reconstruction
259
Infection
Infections that occur in the setting of prosthetic implanta-
tion must be treated aggressively. If they are diagnosed
early, involve only the superficial soft tissue, and are
treated aggressively, it is often possible to salvage the tis-
sue expander or implant (Fig. 6-24).
If they involve the prosthetic device itself, this repre-
sents a much more difficult situation in that I believe that
it is very hard to sterilize an infected prosthetic implant
(Fig. 6-25A). This implant infection required removal of
the device (Fig. 6-25B). A period of 6 months was allowed
to elapse to realize wound equilibrium. Because of the vol-
ume requirement and both quantitative and qualitative
tissue deficiencies, the reconstruction was carried out
with a bipedicled transverse rectus abdominis myocuta-
neous (TRAM) flap (Fig. 6-25C), which resulted in a very
satisfactory outcome shown 8 months following surgery
(Fig. 6-25D).
In either situation, the patient should be treated
aggressively with broad spectrum antibiotic coverage. The
organism in question is most likely a gram-positive coc-
cus, either Streptococcus sp. or Staphylococcus aureus.
I prefer to use a combination of a semisynthetic penicillin,
aminoglycoside, and clindamycin. Alternatively, a drug
such as ampicillin (Unasyn) can be used.
The usual presenting signs and symptoms are ery-
thema, tenderness, and/or fever. An elevated white blood
cell count (WBC) and erythrocyte sedimentation rate
(ESR) may or may not be present. Following the institu-
tion of antibiotic therapy there should be a clinical
response within 72 hours. If there is no significant
response within this time frame a return to the operating
room should be considered. The bacteriology of pros-
thetic implant infections has been extensively reviewed in
Chapter 3, and the reader is encouraged to refer to the ref-
erences in that chapter for details regarding possible etio-
logic organisms and their treatment.
If the patient shows a clinical response to the intra-
venous antibiotic therapy, the therapy should be contin-
ued for 10 to 14 days at home. Additional antibiotics can
be given for 1 to 2 weeks thereafter. I most consult an
infectious disease specialist to help select the most
appropriate antibiotic and to determine the duration
of therapy.
One caveat about skin color changes and implants is
in order. Usually it is very obvious to a clinician when a
breast implant infection is present. The one situation
that may be confusing is erythema occurring in the skin
of a previously radiated patient. It is not common to per-
form an implant-based breast reconstruction following
radiation, but with the rapidly increasing numbers of
patients requiring mastectomy for local recurrence after
a previous lumpectomy, more and more implants are
being used in this setting. Such patients can develop skin
changes that mimic cellulitis. They are treated for the
presumptive cellulitis, usually with a very slow or little
response. A more cautious move to reoperation is in
order when treating skin changes in this subgroup of
patients.
Skin Loss
In the acute setting following immediate breast recon-
struction with a tissue expander, skin loss usually
occurs at the distal margin of the skin flap. The manage-
ment of this problem depends on several factors. The
most important factors in dictating treatment include
the extent of the problem, whether total muscle cover-
age of the expander was achieved at the surgery to place
the expanders, and the anticipated need for chemother-
apy. If this area is small and occurs in a setting where
total muscle coverage was achieved over the expander
and chemotherapy will not be administered, then non-
operative management with the application of oint-
ments and dressing changes with as minimal an office
débridement regimen as required will usually lead to
healing.
A more aggressive approach to wound management is
warranted if total muscle coverage was not achieved
(Fig. 6-26) or the area is somewhat large, or if adjuvant
chemotherapy might be delayed by a wound complica-
tion. In such a setting a return to the operating room for
excision of the threatened skin (Fig. 6-26B,C) and wound
reclosure is usually successful in achieving healing and
preventing wound separation and possible loss of the tis-
sue expander. In these situations, it may be necessary to
remove some or all of the fluid that had been placed in
the expander to permit wound reclosure without tension.
Such a maneuver often facilitates advancement of the
skin flaps and results in wound closure without tension
(Fig. 6-26). This strategy was successfully employed to
salvage the tissue expander in this case. In these situa-
tions the aggressive approach is really the conservative
approach.
The following case illustrates an example of signifi-
cant skin loss in a patient who had a previous lumpec-
tomy and radiation therapy of the left breast. She
required a mastectomy for local recurrence and
requested a bilateral mastectomy. She refused the place-
ment of additional scars elsewhere; therefore she under-
went placement of a submuscular tissue expander
(Fig. 6-27A). She developed a large area of ischemia on
the inferior skin flap of the left breast. The area became
demarcated and thus early excision was undertaken
(Fig. 6-27B). Primary wound closure was successful and
the tissue expander was salvaged (Fig. 6-27C). She
underwent tissue expansion and had the successful com-
pletion of her breast reconstructions with the subse-
quent placement of saline implants (Fig. 6-27D).

260
Reoperative Plastic Surgery of the Breast
FIGURE 6-24. A–B, Infection at site of immediate left breast reconstruction noted 2 weeks following
surgery. Treated with aggressive antibiotic therapy, including 3 weeks of home IV antibiotics in con-
junction with the infectious disease consultant. C–D, There was resolution of infection and successful
completion of reconstruction.

FIGURE 6-25. A, Infection of left breast implant used for reconstruction noted 6 weeks after place-
ment of smooth-walled saline implant. There was drainage from the wound and involvement of the
implant with the infectious process. B, Treatment required removal of implant and delayed primary clo-
sure. C, Reconstruction was delayed 6 months to achieve wound equilibrium and was accomplished
with bipedicled TRAM flap. D, AP view demonstrating satisfactory outcome of breast reconstruction 8
months following surgery.

262
Reoperative Plastic Surgery of the Breast
FIGURE 6-26. A, Ischemic skin necrosis noted at margin of
superior and inferior skin flaps overlying a tissue expander used
for an immediate left breast reconstruction. There was incom-
plete muscle coverage of expander at the time of its insertion. B,
Patient is immediately returned to the operating room for exci-
sion of the ischemic skin. C, Fluid is removed from expander to
allow a tension-free skin reapproximation. D, Expander is sal-
vaged. E, Patient subsequently has placement of silicone gel
implant, which results in a satisfactory breast reconstruction.

Chapter 6
Revision of Implant Breast Reconstruction
263
FIGURE 6-27. A, Larger area of ischemic necrosis of inferior skin flap of left breast in patient who
underwent bilateral immediate breast reconstruction. Total muscle coverage was achieved on each side.
B, Because of the size of the area, I elected to excise the nonviable skin and perform wound reclosure in
the operating room. C, Removing fluid from expander permitted a tension-free closure of wound. D,
Subsequent implant placement achieved satisfactory bilateral breast reconstruction. The reoperation
provided several advantages to the patient. Expansion was initiated earlier and completed earlier than
it would have been without the excision, and appearance of skin overlying breast was superior to what it
would have been had an excision of this area not been undertaken.

264
Reoperative Plastic Surgery of the Breast
Expander Malposition
As noted previously, during a staged breast reconstruction
with a tissue expander and subsequent implant placement, I
focus a good deal of attention on correctly placing the tissue
expander at the first stage. Despite this, malpositions of the
expander do occur. These are the result of either inaccurate
placement of the device initially, or shifting of the expander
early in the postoperative course as a result of the develop-
ment of a biofilm or seroma that prevents tissue in growth
into the device. This lubrication effect at the device–tissue
interface allows the tissue expander to move or rotate as
noted in the left breast of the patient pictured in Figure 6-28
or to shift position in multiple directions (Fig. 6-29). In my
experience this problem appears to be more common fol-
lowing immediate breast reconstruction. It can be seen in
both unilateral and bilateral breast reconstructions.
Perhaps the most common form of malposition
relates to the lower pole of the tissue expander. It is not
uncommon for it to be either too high or too low. It is
more predictable to correct the expander that is too low.
This is because it is easier to raise the level of the
implant (the lower pole contour and the IM fold level)
and achieve greater predictability in maintaining this
position than it is to lower the IM fold, which may result
in a tendency for the implant to continue to descend
with time. This is particularly true when the use of a
large implant (>450 cc) is planned because there is real
potential for bottoming out in this situation if the infe-
rior periprosthetic capsule tissue is entirely released
to establish the correct level for the lower pole of
the implant (the new IM fold). This is especially seen
when a smooth-surfaced saline implant is used for the
reconstruction (Fig. 6-30).
FIGURE 6-28. Counterclockwise rotation of left short-height
tissue expander placed at the time of mastectomy in patient
undergoing immediate bilateral implant-based breast recon-
struction.
FIGURE 6-29. Actual shift in position of both tissue expanders
in patient who underwent immediate bilateral breast recon-
struction. Note extreme lateral malposition of the right side
device and marked asymmetry of position, including IM fold
level.

Chapter 6
Revision of Implant Breast Reconstruction
265
Most of these asymmetries are minor, or of the degree
that they can be addressed at the time of implant
exchange by adjusting the periprosthetic capsular space at
the time of implant placement (Fig. 6-30). On the other
hand, if there is a major shift of the device or if a marked
asymmetry of IM fold position of the breasts is noted, cor-
rection of the expander position should be undertaken
before placing the implants (Fig. 6-30). This is especially
true for expanders that are superiorly malpositioned. In
this setting I believe that it is important to reposition the
expander for several reasons. Continued expansion in this
setting does not result in tissue expansion where it is
needed, namely in the lower pole, and merely results in
thinning of the upper pole tissues. In addition, to achieve
symmetry of the breast levels, a complete inferior capsulo-
tomy with dissection into the lower thoracic subcuta-
neous adipose tissue will be needed. This may result in an
inferior malposition of an implant or bottoming out when
the use of a large implant (>450 cc) is planned.
If the surgeon elects to use a smooth-walled implant
after a total release of the inferior capsule implant, sizes
with a volume greater than 450 cc (approximately 1 lb)
should be used only very cautiously. These large implants
can settle inferiorly because the weight of the implant is
supported only by the subcutaneous tissue in the lower
aspect of the reconstructed breast. Inferior malposition in
this setting may pose a significant problem, especially in
the patient with thin tissues. A textured implant may pro-
vide some additional protection against inferior malposi-
tion due to tissue ingrowth prompted by the textured
surface.
At the first stage of expander positioning, the goal is to
match the level of the opposite IM fold. Many times an
asymmetry of the folds becomes apparent during the
expansion process. If the fold is too high, this can be recti-
fied by lowering it at the time of implant exchange by per-
forming a capsulotomy with incremental lowering of the
fold to the correct level, which is marked preoperatively
(Fig. 6-30B). This is done using electrocautery dissection
illuminated with a headlight or lighted retractor (Fig. 6-31)
to release the inferior capsular tissues. Following this
adjustment, the selected implant is placed, it is inflated if it
is a saline implant, and a temporary wound closure is per-
formed with the patient placed in the sitting position at 90
degrees. When symmetry of the IM fold with that of the
contralateral breast is verified, a standard three-layer clo-
sure of the capsule, deep dermis, and skin is performed.
Early intervention to correct expander malposition is
illustrated by the following patient who underwent a bilat-
eral mastectomy for an intraductal right breast cancer and
a multifocal ductal carcinoma in situ (DCIS) of the left
breast (Fig. 6-32A). Preoperatively she was noted to have A
cup breasts with a base width of 12 cm. Note the lateral
inclination of her breast and the curvature of her chest
wall on both sides (she may have had a forme fruste of pec-
tus carinatum). She desired much more breast fullness
postoperatively. For this reason she underwent the place-
ment of low-height tissue expanders with a base width of
13 cm to accommodate an implant that would allow us to
increase her breast size substantially. There was significant
malposition of both expanders with marked superior lat-
eral displacement of the right tissue expander and a lateral
malposition of the left-sided device, along with an obvious
asymmetry of the IM folds (Fig. 6-32B). This required an
unplanned revision to reposition the expanders (Fig. 6-
32C). This improved their position, but they were not in
optimal position because they were displaced away from
the parasternal area (Fig. 6-32D). At the time of implant
placement a significant medial capsulotomy was necessary
on both periprosthetic capsules (Fig. 6-32E). We used a
high-profile silicone gel implant with a base width of 14
cm and a volume of 600 cc to complete the reconstruction.
These implants produced a very satisfactory appearance
and excellent symmetry of the breasts (Fig. 6-32F).
The plan from the start was to use a large-volume
breast implant based on the patient’s desire for eventual
breast size. For this reason I believe that it is important to
have the periprosthetic scar tissue as a supporting struc-
ture for such a large implant. Completely releasing and
removing the potential support of the implant by this scar
tissue in the inferior aspect of the breast at the time of
exchanging the expander for the implant often produces
a significant chance of the implant bottoming out.
Therefore we performed a correction of expander posi-
tion by relocating it to the appropriate level (Fig. 6-32D)
before placing the implant selected for her breast recon-
struction. Also of note in cases like this is that continuing
to expand the upper chest soft tissues when an expander
is malpositioned superiorly will cause thinning of these
tissues as well as an inadequate molding of the inferior
tissue envelope where it is most needed. In such cases
I believe early intervention for correction of the expander
malposition contributes to a better long-term outcome
(Fig. 6-32F).

266
Reoperative Plastic Surgery of the Breast
FIGURE 6-30. A, Discrepancy in level of IM folds created by
tissue expander placement in the form of a delayed breast recon-
struction. B, Outline for a release of lateral two thirds of inferior
periprosthetic capsule tissue to achieve IM fold symmetry. C,
Note excellent symmetry of IM folds following second stage of
reconstruction with silicone gel implant placement.

FIGURE 6-31. Correction of malposition most often requires a
capsulotomy. Inferior capsulotomy incision is marked and
release of the scar tissue is best done using the electrocautery
device under direct vision with illumination of surgical field.
FIGURE 6-32. A, Preoperative AP view of patient who will undergo bilateral mastectomy and desires
immediate breast reconstruction with an implant-based reconstruction strategy. She desires much
larger breasts. Note curvature of chest wall and lateral position and inclination of her breasts. B, She is
noted to have an extreme degree of bilateral tissue expander malposition. (continued)

268
Reoperative Plastic Surgery of the Breast
FIGURE 6-32. (CONTINUED) C, This malposition required an interval procedure to reposition
expanders. D, Expander position is still not optimal as the medial aspects of the expanders are wide
apart. E, The planning before insertion of high-profile silicone gel implants (14 cm, 600 cc) includes sig-
nificant bilateral medial and superomedial capsulectomies (outlined in green) to enhance cleavage.
Excellent breast shape and symmetry are seen on AP (F) view at 3 months following placement of
implants.

Chapter 6
Revision of Implant Breast Reconstruction
269
REINSERTION OF ANOTHER TISSUE
EXPANDER TO REVISE AN
INADEQUATE IMPLANT
RECONSTRUCTION—REVISION OF THE
PERIPROSTHETIC CAPSULAR SPACE
WITH CHANGE IN DEVICE DIMENSION
Patients often present with breast asymmetry related to
the positioning of an implant or tissue expander and the
device itself. The implant may have an inadequate volume
or base dimension to match the opposite breast or the
tissue expander dimensions may be inadequate to create
the periprosthetic space dimension necessary for breast
symmetry at the second stage. In these cases both the
abnormal device position and the device itself (the
implant or the tissue expander) must be changed. Such a
situation is illustrated by the following patient. She pre-
sented to the office with a marked asymmetry of the
breasts after a left breast reconstruction with a silicone gel
implant (Fig. 6-33A,B). The reoperative plan entailed the
removal of her implant and a significant inferior reposi-
tioning of the IM fold to match the other breast (Fig. 6-
33C). This was done with the placement of another tissue
expander with a base dimension to match the opposite
breast. She subsequently underwent the placement of a
shaped textured silicone gel implant with a base width of
14 cm and a volume of 540 cc, which produced satisfac-
tory symmetry with the opposite breast and the outcome
that the patient sought with the reoperative procedure
(Fig. 6-33D,E). The tissue expander used in this case
established the pocket necessary for the aesthetically
correct breast dimension, and the scar tissue from the
capsule provided support for the larger implant that
was used.
If the decision is made to lower the IM fold level by
releasing the periprosthetic capsular tissue inferiorly,
I find it helpful to place multiple sutures (3-0 Prolene)
between the superficial fascia (Scarpa layer) and the chest
wall fascia (Fig. 6-34). This suture can provide additional
tissue support and may act as a barrier to limit inferior
implant malposition. This is especially helpful if a single-
staged correction is planned.
FIGURE 6-33. Severe breast asymmetry following left breast reconstruction done with implant seen
on AP (A) and oblique (B) views. (continued)

FIGURE 6-33. (CONTINUED) C, The plan for revision is to
“retreat” and place a new tissue expander with an adequate base
width in the appropriate position to create symmetry with the IM
fold of the opposite breast, following placement of shaped tex-
tured silicone gel implant with base width of 14 cm and 540 cc of
gel, patient demonstrates a very satisfactory outcome from this
revision sequence on AP (D) and oblique (E) views.

REVISION AT THE SECOND STAGE, OR
ADJUSTMENTS AT THE TIME OF
IMPLANT EXCHANGE
It is true that most adjustments of the expanded soft tissue
envelope in staged tissue expander–implant reconstruc-
tions are in fact made at the time of implant exchange.
These adjustments are most often made to correct asym-
metries produced by malposition of the expander, alter or
define the IM fold, or increase the projection or alter the
shape of the reconstructed breast.
The expander position can be too high, too low, too
lateral, or too medial. Most of these problems can be
addressed with manipulations of the periprosthetic cap-
sular tissue in the form of capsulotomies, focal capsular
excisions, or capsular scoring and internal suture capsu-
lorrhaphies. In these situations the periprosthetic scan
tissue capsule is often the surgeon’s ally. Manipulations of
the capsule can substantially improve the appearance
of an implant breast reconstruction. By far the most diffi-
cult problem to successfully address is the expanded space
that is too medial and produces medial implant malposi-
tion. If it is bilateral, symmastia or pseudosymmastia can
be produced. This is because there is so little tissue near
the chest wall medially that can hold sutures. In addition,
any sutures on the deep surface of the presternal or
parasternal breast tissue can easily produce dimpling.
Therefore simple suture capsulorrhaphies here tend to
be unsuccessful, and often the elevation of capsular flaps
is necessary to permit the best chance for long-term
correction.
SUPERIOR MALPOSITIONS OF
EXPANDER OR IMPLANT
Superior malpositions of the expander can most often
be corrected at the time of implant exchange by inferior
capsulorrhaphy and incremental inferior dissection.
The implant position is checked on the operating table
by positioning the patient in a sitting position at 90
degrees on the table and assessing the lower pole sym-
metry. I often suture the superior capsular space to close
it down in an attempt to limit the possibility of recurrent
superior implant malposition. Care must be taken not to
dimple the skin or cause abnormal contours if this
is done.
As discussed previously, an additional important caveat
is to be careful with complete inferior capsular releases in
the setting of placing a large-volume implant, especially if
the implant is a smooth-walled saline with a volume of
450 cc or greater. Such a situation may lead to inferior
implant migration or bottoming out, in essence producing
the reverse deformity of what was previously corrected. To
help prevent or minimize this potential problem, 3-0
Prolene sutures can be placed in the superficial fascia and
attached to the fascia of the chest wall. This is illustrated
in Fig. 6-34 in sagittal section. The sutures placed joining
the SFS to the chest wall confer an extra barrier to limit
inferior implant migration.
In general, superior malposition is the easiest problem
to correct while exchanging the expander for an implant.
The surgeon marks the correction before surgery with the
patient in the standing position (Fig. 6-35A). After remov-
ing the tissue expander, an inferior capsulotomy is per-
formed and inferior dissection proceeds incrementally
under headlight assistance (see Fig. 6-31) with the elec-
trocautery device. The selected implant is positioned and
the patient is placed in the sitting position at 90 degrees
on the operating table. The capsule and other tissues in
the wound are closed and a careful assessment for ade-
quacy of the correction is made. When IM fold symmetry
and the desired appearance of the implant reconstruction
are achieved, permanent closure of the wound is carried
out in three layers. I often place on the repair as an exter-
nal bolster a thick piece of foam rubber that is cut to con-
form to the contour of the IM fold or of the lower breast
pole (see Fig. 8-14E). The result achieved is fairly pre-
dictable, and in this case the correction is shown in
Figure 6-35B.
Chapter 6
Revision of Implant Breast Reconstruction
271
FIGURE 6-34. Sagittal section illustrating placement of 3-0
Prolene sutures between SFS and fascia of chest wall. These may
help limit the possibility of additional implant migration inferiorly.

272
Reoperative Plastic Surgery of the Breast
EXPANDER OR IMPLANT TOO LOW
If the lower level of the expander is too low at the conclu-
sion of the expansion process, or if a previously placed
breast implant is too low, then the lowest portion of the
periprosthetic capsular space must be superiorly reposi-
tioned. If the IM fold is also low, it too can be superiorly
repositioned or reconstructed at a higher position if indi-
cated. This alteration in the capsule most often can be
done internally with a capsulorrhaphy. The internal
approach most often involves either a suture plication of
the capsule (most often done with a strong permanent
monofilament suture, e.g., 3-0 Prolene) or a focal or strip
resection of the capsule tissue combined with a suture
repair, sewing raw edge of capsule to raw edge of capsule,
again using a permanent monofilament suture. If the IM
fold requires reconstruction, this too can be accom-
plished using either an internal approach with sutures or
an external incision and a flap of skin that is de-epithelial-
ized. This external approach entails anchoring the lead
edge of the dermal flap to the chest wall as described by
Ryan.9 I prefer the internal approach,10 which in my opin-
ion consistently achieves good results and avoids an
external scar. Such a maneuver virtually always raises the
level of the IM fold.
If the level of the lower pole of a previously placed
implant or expander is too low, it is best addressed by
placing capsular sutures to raise the implant level by pli-
cating the capsule (Fig. 6-36). I prefer to use a permanent
monofilament suture (Fig. 6-37), and I commonly use a
3-0 Prolene suture. The best approach is to place two
rows, the first interrupted and the second a running layer
to close the capsular tissue over the knots from the inter-
rupted row of sutures. It is my experience that this type of
repair provides sufficient strength to maintain the correc-
tion when implants with a volume less than 450 cc are
used.
RAISING THE INFRAMAMMARY FOLD—
CAPSULAR SUTURE TECHNIQUE
Superior repositioning of the IM fold begins preopera-
tively by analyzing the discrepancy between the IM folds
when the patient is completely upright, preferably in the
standing position (Fig. 6-38A). This patient (Fig. 6-38A)
is noted to have an asymmetry of her IM folds at the
completion of her tissue expansion process. The
exchange procedure entails the placement of 450-cc
smooth round silicone gel implants. The technique of
periprosthetic capsule suture plication will be used
(Fig. 6-37). The necessary repositioning of the IM fold
and capsular suture placement was outlined on the
patient’s skin preoperatively (Fig. 6-38B). She was cor-
rected with the technique outlined (Fig. 6-37B). The
patient is shown 4 months following surgery, before her
nipple reconstruction, with excellent symmetry of the IM
folds (Fig. 6-38C).
FIGURE 6-35. A, Asymmetric position of lower contours of breasts at completion of tissue expansion.
Inferior-medial capsulotomies outlined for correction. B, Two years following reconstruction with
shaped textured silicone gel implants, patient developed Baker III capsular contracture of right breast.

RAISING THE INFRAMAMMARY FOLD—
FOCAL CAPSULE EXCISION AND
DIRECT CAPSULAR SUTURE
TECHNIQUE (RAW EDGE TO RAW EDGE
OF CAPSULE)
Focal capsule excision and direct capsular suture tech-
nique is my preferred method for correction of implant
malposition when a large implant has been used (>450 cc)
or in situations where a previous suture capsulorrhaphy
has been unsuccessful. It is also particularly helpful in
cases of lateral implant malposition where the implant
constantly stresses the repair with the patient in the
supine position due to the effect of gravity. This technique
was used for correction of an inferior implant in the fol-
lowing patient.
This 45-year-old patient experienced progressive infe-
rior migration of a 550-cc smooth-walled saline implant
following left breast reconstruction with a latissimus dorsi
flap (Fig. 6-38D). As in all of these cases, the correction was
planned perioperatively by placing fingers against the skin
of the lower pole of the breast, simulating the correct posi-
tion of the IM fold (Fig. 6-38E). I tend to place circles with
an × in the center on the areas under my fingers (Fig. 6-
38F) and use these marks as a guide to the eventual suture
line for raw edge of capsule to raw edge of capsule apposi-
tion when working inside the capsule. At surgery the cor-
rection involves opening the anterior capsule and
removing the indwelling tissue expander or implant. Next,
with the assistance of a headlight or a lighted retractor, a
resection of a strip of capsule in the inferior recess is car-
ried out after the area to be excised is outlined on the cap-
sular tissue (Fig. 6-38G). A strip of capsular tissue is
resected from the inferior recess below the desired new
level of the IM fold (Fig. 6-38H), and the incised raw edges
of the capsule are sutured with a row of internally placed
3-0 Prolene sutures that correspond to the skin markings
(Fig. 6-38I). Every other suture is tied and the implant is
replaced with an accompanying closure of the skin wound.
With the patient placed in the sitting position as close to 90
degrees as possible on the operating table, an assessment
of the correction is made (Fig. 6-38J). If the folds are sym-
metric, the remainder of the sutures are tied and closure of
the wound in three layers proceeds in a normal fashion.
The correction achieved with this 45-year-old patient is
noted at 1 year postoperatively (Fig. 6-38K).
If the correction is incomplete, which is indicated when
the IM fold is still positioned too low, then additional
sutures are placed in a second, more superiorly positioned
row to further raise the IM fold. Another segment of the
capsule can be excised above the previous capsular exci-
sion. Conversely, if the fold was initially overcorrected, then
the sutures are removed and more inferiorly positioned
sutures are placed. As symmetry is achieved, the wound
closure is performed in standard three-layer fashion.
Chapter 6
Revision of Implant Breast Reconstruction
273
FIGURE 6-36. Diagram illustrating suture plication of
periprosthetic capsule to alter dimensions of the space and the
position of space relative to surface landmarks (i.e., either IM
fold or lateral extent of implant position).
FIGURE 6-37. Technique of suture placement in periprosthetic
capsule.

274
Reoperative Plastic Surgery of the Breast
FIGURE 6-38. A, Moderate asymmetry of IM folds noted before exchange of tissue expanders for high-
profile silicone gel implants. B, Correction of inferior fold malposition outlined on left breast. C, Four-
month postoperative appearance reveals symmetric IM folds. D, Marked inferior malposition of a 550-cc
smooth-walled saline implant placed beneath latissimus dorsi musculocutaneous flap for left breast
reconstruction 6 months previously. Patient cannot wear clothing with this degree of asymmetry. E,
Correction of IM fold is simulated by digital pressure against skin of lower pole of implant. F, Correction,
which includes the capsule tissue to be resected and the position of suture placement, is outlined. G,
Markings are made with methylene blue to illustrate position and dimension of capsule tissue to be
resected. H, Capsule is resected. (continued)

Chapter 6
Revision of Implant Breast Reconstruction
275
FIGURE 6-38. (CONTINUED)

276
Reoperative Plastic Surgery of the Breast
The plication sutures change the internal volume
dimensions of the periprosthetic capsular space (see
Fig. 6-36). This can have a very powerful effect on the
shape an implant produces in the overlying skin.
The focal capsule excision and direct capsular suture
technique can be used not only to change the level of an
implant but also to affect the way the implant fills
out the soft tissue envelope. I have found that tight-
ening the periprosthetic capsule is a helpful adjunct in
treating the problem of rippling, as well as for
defining the IM fold. We will also discuss this more com-
pletely.
FIGURE 6-38. (CONTINUED) I, Cut edges of capsule are
sutured together with 3-0 Prolene sutures. J, Patient is posi-
tioned at 90 degrees on operating table, correction is evaluated,
and symmetry of IM folds is checked. K, Pre-operative asymme-
try due to implant malposition and corrected breast shape is
seen 1 year following surgery.

Chapter 6
Revision of Implant Breast Reconstruction
277
An IM crease in a patient who has undergone implant
reconstruction is often not as well defined as that seen on
the opposite breast. This is most frequently noted in
patients with “heavy” tissues and a thick deep adipose
layer in the lower thoracic area. Increased definition of
the crease can be accomplished by focally defatting the
deeps adipose layer and intermittently suturing the super-
ficial fascial system (SFS or Scarp’s fascia) to segmental
openings in the lower aspect of the peri-prosthetic cap-
sule.
The intended level of the fold is outlined on the patient’s
skin and it is usually not necessary to change it. The
implant is removed and the peri-prosthetic capsule is inter-
mittently incised with the electrocautery in 2 cm segments,
exposing the deep layer of adipose tissue. The dissection is
brought superficially until the SFS or Scarpa’s fascia is
identical beneath the intended level of the IM fold. A small
amount of deep fat is excised. Sutures are placed between
the SFS superficially and the posterior edge of the divided
peri-prosthetic capsule below. Leaving 1 cm segments of
intervening capsule provides some insurance against infe-
rior migration of the implant, especially if a large implant is
being used.
An example of this technique is illustrated by the
patient shown in Figure 6-39A-C.
ESTABLISHING BETTER DEFINITION OF
THE INFRAMAMMARY FOLD
In general, patients with a husky build and corresponding
thick layers of adipose tissue are not good candidates for
implant reconstruction. The implants needed in such
patients tend to be very large because this type of
physique tends to swallow up the implant.
Such patients often manifest another problem, namely
poor definition of the IM fold that is created with an
implant breast reconstruction. This can be aesthetically
undesirable, especially if there is relatively good definition
of the opposite IM fold. In these cases a redefining of the
IM fold is necessary to achieve symmetry with the oppo-
site IM fold, as illustrated by the following case.
This patient (Fig. 6-39) required a left mastectomy for
treatment of her breast cancer and wished to undergo an
immediate left breast reconstruction. She preferred an
implant-based reconstruction. She had significant breast
ptosis and the mastectomy was performed using a Wise
pattern skin excision. She also requested a contralateral
mastopexy. In addition, she had undergone a lower
abdominal midline incision for a hysterectomy. This was
done in stages, with tissue expander placement and
mastopexy as the first stage. The patient had a thick adi-
pose tissue layer in the lower thoracic area, and the IM
fold generated by the expander was ill defined and differ-
ent from the opposite IM fold (Fig. 6-39A,B).
The patient required a large implant for symmetry.
Because the opposite IM fold was very well defined, I felt
that part of her reconstruction required redefinition of her
IM fold (see Fig. 6-34). This was accomplished by making
segmental incisions in the periprosthetic capsule along
the length of the fold (Fig. 6-39D). We dissected toward
the skin to obtain exposure of the SFS in order to place
sutures from the SFS to the posterior aspect of the
periprosthetic capsule (Fig. 6-39C) as outlined on the skin
preoperatively. Additional sutures were then placed in the
capsule to enforce the repair and to make the fold smooth
externally. Not releasing the capsule in its entirety pro-
vides an additional margin of safety for preventing signifi-
cant inferior implant malposition when a large implant is
selected.
The technique is as follows. The level of the new crease
is outlined on the skin of the breast by digital pressure as
outlined previously. Marks are then placed on the skin
(Fig. 6-39C). During surgery, after the tissue expander is
removed, discontinuous incisions are made in 3-cm long
segments (Fig. 6-39D). Dissection proceeds superficially
toward the skin until the SFS is reached. A small amount
of the adipose tissue in the deep subcutaneous fat layer is
excised in the shape of a narrow trough exactly in the line
of the desired fold to permit accurate suture placement
and the development of crease in the skin. A 3-0 Prolene
suture is placed in the posterior capsule and also in the
SFS. Additional sutures are placed in the SFS along the
IM fold through additional focal capsulotomy incisions.
The intervening periprosthetic capsular tissue is main-
tained (Fig. 6-39E), and 3-0 Prolene sutures are placed in
this capsular tissue. An example of such a fold created
using this method is illustrated by this patient (Fig. 6-39 F,
G), who is seen before exchange of her expander for an
implant. There is poor definition of the IM fold created by
the tissue expander. Internal suture redefinition of the
fold was performed exactly as described, and 6 months
following the revision procedure, a definite crease is seen
that better approximates the appearance of the contralat-
eral IM fold (Fig. 6-39F, G). This is best illustrated by com-
paring the inferior-medial fold definition preoperatively
(Fig. 6-39A) with that noted following correction (Fig. 6-
39F, G).
I have found the focal capsule excision and direct
capsular technique of suturing the SFS layer (see
Fig. 6-34) to the posterior capsule to be an anatomically
sound and reliable method of creating a defined IM
fold. In the patient with a very thick subscarpal adipose
layer, it is often beneficial to resect a good portion of
this deep fat along the intended IM fold to enhance the
correction.

278
Reoperative Plastic Surgery of the Breast
FIGURE 6-39. Somewhat obese patient requires left mastec-
tomy for breast cancer and requests implant-based breast recon-
struction. She has significant bilateral breast ptosis, and the plan
is for a right mastopexy along with immediate placement of tis-
sue expander on the left, both done with a Wise pattern. A,
Appearance of tissue expander before exchange. B, Note ill-
defined IM fold on side of expander. C, Sagittal section depicting
layers of superficial fascia and posterior capsule to be altered to
produce IM fold. (continued)

Chapter 6
Revision of Implant Breast Reconstruction
279
FIGURE 6-39. (CONTINUED) D, Focal incisions in capsule
are made and dissection proceeds superficially toward skin to
access superficial fascia (different patient). E–F, Purchase on
fascia is obtained with 3-0 Prolene sutures along course of
desired fold. Remainder of capsule is left intact to support
weight of large implant to be placed.

SUPERIOR IMPLANT MALPOSITION—
CORRECTION IN THE OBESE PATIENT
WITH A THICK LOWER THORACIC
ADIPOSE TISSUE LAYER
As previously mentioned, obese patents and those with
thick adipose layers in the lower thoracic region are usu-
ally suboptimal candidates for implant breast reconstruc-
tion. In general they require very large implants, and often
even large implants do not produce the desired shape in
the reconstructed breast. This may be due to large torso
dimensions, but more often it is related to the fact that
implants are obscured by the thickness of the subcuta-
neous adipose layer in patients with a heavy body habitus.
For this reason I tend to encourage the use of autologous
methods in patients of this body build. At times these
options are unavailable due to patient preference, previ-
ous surgery, or other anatomic factors.
When an implant-based breast reconstruction is per-
formed in a heavy patient, there are often requests for
improved shape as part of the reoperative breast surgery
procedure. This is perhaps most commonly noted in the
lower pole, where definition of the IM fold may be subop-
timal or not apparent at all.
In patients with a thick layer of adipose tissue in the
lower thoracic area who require revision of a previously
placed implant that is superiorly malpositioned, I have
had the most consistent success by removing the implant
and placing a tissue expander whose lower aspect is posi-
tioned superficially, i.e., above the superficial fascia. This
method of retreating has been helpful in that it allows
relatively precise positioning of the new IM fold at the
proper level. The dissection to achieve correction is as
described earlier for tissue expander placement (see Fig.
6-18A–C). It is necessary in obese patients with thick adi-
pose layers such as the one illustrated in Figure 6-40 to
position the lower pole of the expander in the deep
aspect of the superficial adipose layer above the superfi-
cial fascial system. The expansion process can be done
slowly, allowing the generation a supporting layer of
periprosthetic capsule tissue and the development of a
natural-appearing IM fold. Attempting to do this in one
stage with a capsulotomy and implant repositioning
risks inferior implant malposition because there is mini-
mal tissue support garnered from the superficial adipose
layer. I have found that this extra procedure adds a mar-
gin of safety and increases the predictability of revisions
done in this setting. The following case illustrates this
strategy.
This 42-year-old somewhat obese patient had under-
gone a right modified radical mastectomy and subse-
quently had a staged breast reconstruction with a tissue
expander and the secondary placement of a saline
implant. She presented for correction of a significant
postsurgical breast asymmetry with dissatisfaction
related to the size, shape, and position of her recon-
structed right breast (Fig. 6-40A). The plan for revision
involved the placement of a tissue expander with the cor-
rection of inadequate breast dimension (base width and
height) along with the creation of a new, more well-
defined IM fold positioned at the appropriate level to
match that of the opposite breast (Fig. 6-40B). Because
the opposite breast had good definition of the IM fold, it
was important to place the lower pole of the tissue
expander in a deep portion of the superficial adipose layer.
This was done, the expansion was completed, and she was
reconstructed with a textured shaped saline implant
(Fig. 6-40C,D). The patient demonstrates a highly satisfac-
tory breast appearance from the standpoint of shape,
dimension (more adequate base width), and symmetry of
the breast as a result of this reoperative procedure. The
definition and contour of the newly created fold highlight
the improvement in breast appearance.
LATERAL IMPLANT MALPOSITION
In its natural state the breast exhibits medial fullness and
extends from the parasternal area laterally to, but not
beyond, the anterior axillary line. However, many implant
breast reconstructions extend too far laterally, reducing or
eliminating the superior fullness and creating a situation
wherein the patient will bump the lateral aspect of the
breast implant with her upper inner arm. This lateral mal-
position is due to either excessive lateral dissection; an
implant that accidentally prolapses into the space of a pre-
vious axillary dissection; or simply the stretching of the
lateral chest wall tissues under the influence of gravity,
which primarily exerts its effects when the patient is lying
in the supine position.
Lateral implant malposition can be treated by suture
capsulorrhaphy of the lateral capsular space. If a large
implant has been used, I achieve the correction by clos-
ing down this lateral capsular recess with a focal exci-
sion of lateral capsule and direct suture of the raw edges
as outlined earlier, or by correcting this with capsular
flaps (see Fig. 3-75) as previously discussed for correc-
tion of implant malposition following breast augmenta-
tion. I like this method because it allows an extra
thickness of capsular tissue to be sewn to itself with raw
tissue being sutured to raw capsule edge tissue. Two or
three rows of nonabsorbable suture (I prefer a 3-0
Prolene) are most often used to provide sufficient
strength to the repair so that it will permit long-term
maintenance of the correction.
The planning is similar to that done to correct inferior
malposition of the implant. The surgeon uses his or her
examining fingers to manually displace the implant to
the desired position of correction with the patient in the
standing position. The surgeon then places marks on
280
Reoperative Plastic Surgery of the Breast

Chapter 6
Revision of Implant Breast Reconstruction
281
FIGURE 6-40. A, Significant breast asymmetry in the patient with a thick adipose layer who has under-
gone previous delayed reconstruction of right mastectomy defect with tissue expansion and subsequent
placement of saline implant. B, The plan for revision is outlined to address these issues and involves plac-
ing tissue expander of appropriate dimension more superficially (above superficial fascia) and more inferi-
orly at correct position for new IM fold. C–D, Six-month postoperative view following placement of
textured shaped saline implant shows marked improvement in breast symmetry and appearance on AP (C)
and oblique (D) views.

the skin with a marking pen to outline the capsular tissue
to be resected and guide the placement of sutures when
internal capsule suture correction is carried out.
As in the correction of the other types of malposition,
the previous skin incision is opened and a short skin flap
of about 2 cm is raised. The capsule is thus entered at a
different position from the skin incision so that if there
is a dehiscence of either the capsule closure or the skin
closure, the chance of implant exposure is minimized.
The implant is removed and the sutures are placed. A
decision about whether to use a flap of capsular tissue
depends on the thickness and quality of the peripros-
thetic capsule. After the correction is performed, the
implant is replaced and the position of the implant and
shape of the breast is checked both with the patient sit-
ting up on the operating table at 90 degrees and with the
patient in the supine position. I perform a temporary
stapled skin closure before inspecting the contour of the
breast reconstruction with the patient in the supine
position.
MEDIAL IMPLANT MALPOSITION
Medial implant malposition is the most difficult implant
malposition to correct. Very often a number of maneuvers
are required to address it, including a lateral capsular
release, a change of implant, and carefully placed capsular
sutures that are oriented parallel to the lateral border of
the sternum. Almost always a capsulotomy with develop-
ment of the anterior flaps of the capsule raised on both the
anterior and posterior surfaces of the periprosthetic cap-
sular space is used (see Fig. 3-75). The position of the cap-
sule incision is again determined by digitally compressing
the implant laterally and marking the skin when a satis-
factory appearance of the correction has been simulated
over the lateral border of the sternum, similar to what is
illustrated for correction of inferior implant malposition
(see Fig. 6-38E).
Suturing freshly incised edges of the capsule permits
the deposition of collagen at the site of correction and
medially in the parasternal area. I believe this con-
tributes to the maintenance of the correction. I place
permanent sutures of 3-0 Prolene in an interrupted fash-
ion using figure-of-8 suture technique. The concomitant
lateral capsulotomy allows the effect of gravity to work
on the implant to help protect the medial capsular
repair. Following the placement of the implant, a tempo-
rary closure is performed and the breast position is
checked with the patient sitting up at 90 degrees on the
operating table. If the correction is appropriate, closure
of the wound proceeds as explained previously. If addi-
tional sutures are required or if one needs to be removed
due to dimpling of the skin, this maneuver is carried out
before completing the wound closure. After the final skin
closure is completed, I splint the repair by placing a care-
fully fitted piece of thick foam rubber sponge in the
intermammary sulcus or cleavage area (see Fig. 8-14E).
This can be made using straight Mayo scissors to cut a
sterile piece of foam rubber. I secure it with either ben-
zoin or by using the sticky surface of the foam against
the skin and have the patient wear this for 2 weeks. I
limit medial mobilization of the implant for an entire
month following surgery. I have found that this regimen
produces the best chance for a long-term correction of
medial implant malposition (or symmastia if it is bilat-
eral) following breast implant placement.
Such a case is illustrated by the following patient, who
underwent an immediate left breast reconstruction by the
placement of a tissue expander following a modified skin-
sparing mastectomy (Fig. 6-41). The original dissection to
position this device extended too far medially, and a pic-
ture of medial implant malposition was apparent during
the tissue expansion process (Fig. 6-41A). The second
stage of her reconstruction involved removal of the
expander and placement of a silicone gel implant on the
left side, along with a right breast augmentation with a
smooth round silicone implant placed in the retropec-
toral position of her right breast. An attempt to correct
the medial malposition of the left breast shape with a
suture capsulorrhaphy was only partially successful
(Fig. 6-41B). Because of this, the combined implant
reconstruction and breast augmentation produced the
appearance of symmastia.
The patient was disturbed by the symmastia (Fig.
6-41B). In addition to an obvious lack of cleavage, the
patient exhibited lateral rib show (Chapter 2) from the
frontal view with a deficiency of inferolateral breast full-
ness and contour, along with a volume asymmetry
between the augmented right breast (which was larger)
and the left breast reconstruction.
The goals of the reoperative breast surgery in this
case were to restore a relatively normal cleavage space,
recreate a lateral breast contour to match the opposite
breast by concealing the anterolateral ribs, and increase
the overall volume of the implant breast reconstruction
(Fig. 6-41C). These goals were accomplished by per-
forming a lateral capsulotomy to allow the new implant
to extend into a more appropriate lateral position,
repairing the symmastia with a double capsular flap
technique (see Fig. 3-75) done in the medial capsular
region using multiple permanent (3-0 Prolene) sutures,
and increasing the volume and dimension of the
smooth-walled silicone gel implant used for her recon-
struction. These maneuvers produced a pleasing correc-
tion of her breast appearance (Fig. 6-41D). A subsequent
nipple reconstruction done with inferiorly based modi-
fied fishtail flaps (Fig. 6-41E) and an intradermal tattoo
for areolar pigmentation (Fig. 6-41F) completed her
breast reconstruction.
282
Reoperative Plastic Surgery of the Breast

Chapter 6
Revision of Implant Breast Reconstruction
283
FIGURE 6-41. Correction of medial malposition of breast implant used for breast reconstruction. A,
This 41-year-old patient requires left mastectomy and elects to undergo staged reconstruction of breast
with tissue expander, followed by implant with plan for contralateral breast augmentation with silicone
gel implants. Note medial malposition of tissue expander. B, Second stage produced suboptimal breast
reconstruction with medial malposition of implant, which had too narrow a base width for the patient’s
chest dimension. C, This required a revision to correct medial malposition using double capsular flap
technique (see Fig. 3-75)(and not the suture capsulorrhaphy technique as noted on skin). D, Breast
implant with greater base width and volume was chosen, which improved breast silhouette and shape.
(continued)

INCREASING PROJECTION OF AN
IMPLANT BREAST RECONSTRUCTION
The task of increasing the projection of an implant
breast reconstruction generally involves two maneuvers.
The first is to release any constraint imposed on the pro-
jection by the periprosthetic capsule anterior to the
implant. This is done by methodically incising the cap-
sular tissue using parallel radial incisions in the capsule
or crisscrossed incisions (Fig. 6-42D) oriented at right
angles to each other (creating a tic-tac-toe board appear-
ance within the capsular tissue), or by performing a
focal or subtotal capsulectomy (see Fig. 3-98). I prefer
to perform a focal capsulectomy, which in my experi-
ence produces maximum distensibility of the tissues
overlying the implant. Caution must be exercised in
patients with very thin covering tissue because remov-
ing the capsule theoretically can impair the blood
supply to a thin overlying skin flap. This is perhaps a
consideration only in patients who have undergone
either previous subcutaneous mastectomy or multiple
revision procedures for revision of implant breast
reconstruction where the overlying skin flaps may be
scarred and very thin. Otherwise, performing this
maneuver with the electrocautery device using the
coagulation mode set on a low setting (3 to 4) has
proven successful and safe in my hands.
In addition, it is almost always necessary to change the
implant to one with greater projection. When reoperating
on a patient with a saline implant in place, the surgeon
should avoid the temptation to simply overfill the saline
implant in an attempt to increase the projection. This
maneuver will most often produce excessive upper pole
fullness as well as scalloping of the edges, which may be
seen as ripples through the skin.
The following case illustrates the use of multiple focal
capsulectomies combined with a change in implant to one
with more projection to improve the shape of an implant
reconstruction with inadequate lower pole projection
(Fig. 6-42). The patient had undergone bilateral staged
immediate implant-based breast reconstruction and had a
shaped textured implant with a base width of 13.9 cm and
gel volume of 540 cc (Fig. 6-42A,B). She was dissatisfied
with the shape and projection of the lower poles of her
breasts. This was addressed by performing vertically ori-
ented focal capsular excisions in the lower pole (Fig. 6-
42C,E), along with changing to a round high-profile
silicone gel implant with a base diameter of 13.8 cm, a gel
volume of 600 cc, and almost 1 cm greater projection. The
improved projection is evident on the operating table
(Fig. 6-42G), and a 6-month postoperative analysis of the
breasts shows much improved contour and shape of the
lower poles (Fig. 6-42H–I).
Each implant manufacturer includes with its implant
offerings specifications of dimensions that detail the
284
Reoperative Plastic Surgery of the Breast
FIGURE 6-41. (CONTINUED) E, The plan for nipple recon-
struction illustrates symmetry achieved by this reoperative pro-
cedure. F, Intradermal tattoo completes aesthetic revision,
transforming breast mound into lifelike breast facsimile.

Chapter 6
Revision of Implant Breast Reconstruction
285
expected projection. As alluded to several times earlier in
this chapter and in Chapter 3, I believe that the surgeon
should refer to these charts or pamphlets in the selection of
breast implants in virtually every case. The most valuable
information in this regard is the base width and vertical
height of the implant; however, information regarding pro-
jection is also helpful, especially when increasing the projec-
tion of a previous breast reconstruction is the primary goal.
Smooth round implants, whether saline-filled or sili-
cone gel, are available in low-profile, normal-profile, and
high-profile shapes. High-profile implants provide the
maximum anterior projection for a given base diameter. I
find them very useful in breast reconstruction performed
with implants and very helpful in revision surgery where
increased projection of the reconstructed breast is the pri-
mary goal.
FIGURE 6-42. A, This 45-year-old patient had undergone bilat-
eral immediate breast reconstruction done with tissue expan-
sion and shaped textured silicone gel implants. B, Patient was
bothered by shape of breasts, which lacked projection in lower
poles. C, Projection can be increased by modifying the capsule.
The plan was to perform multiple parallel focal capsulectomies
in capsular tissue of lower pole. (continued)

286
Reoperative Plastic Surgery of the Breast
FIGURE 6-42. (CONTINUED) D, Alternatively, a crisscross incision pattern in capsule may be used.
Regardless of technique used, it is important to maintain a segment of capsule intact along edge of inci-
sion to ensure secure closure of capsule. E, Location and pattern for capsulectomies outlined on capsu-
lar tissue surface with electrocautery. F, Each area of scar is excised. G, Smooth-walled high-profile
silicone gel implant is substituted for shaped implant, and immediately on operating table a better
shape and projection of lower pole of breast is noted. (continued)

FOLDS
Folds that are seen through the skin are a definite detrac-
tion from the aesthetic result of implant-breast recon-
struction (Fig. 6-43A,B). Unfortunately, the presence of
folds is not rare. The etiology of folds is multifactorial, but
the primary factors are underfilling of the implant and
inadequate tissue padding. The other factors responsible
for folds in the skin following implant reconstruction are
listed in Table 6-1.
I have had fewer problems with folds since I switched
to the use of a low-height tissue expander and a smooth-
walled silicone gel implant in most of my patients under-
going implant-based breast reconstruction. This is
because there is no stretching (and thinning) of the upper
breast tissues, and the problems associated with underfill-
ing and traction rippling are largely eliminated.
Folds in the skin following breast reconstruction (and
also after breast augmentation) are difficult to completely
correct. This is one of the situations where I underpromise
and try to overdeliver. I inform the patient preoperatively
that it may not be possible to completely correct the folds
and that if we are able to achieve correction right after sur-
gery, the folds may recur in time as her tissues stretch again.
Underfilling of the upper pole of a breast implant is the
common denominator in the genesis of folds seen in
breast reconstruction with a synthetic implant. Relative
underfilling of the upper pole of an implant is very com-
mon when a saline device is used. This applies to both tex-
tured shaped implants and smooth round implants.
Because of this I mention the importance of never under-
filling a saline implant several times throughout this book.
This practice predisposes the patient to an increased like-
lihood of folds in the breast. Paradoxically, significantly
overfilling a round implant (filling a saline implant more
than 50% over the recommended fill volume) can cause
scalloping of the edge. Such overfilling may cause visible
wrinkles in the skin, especially in a patient with thin cov-
ering tissues.
Although it is more commonly seen with saline
implants, the phenomenon is also observed with silicone
gel implants. A glaring example of this is the Inamed
Corp. Style 153 textured shaped silicone gel 13.1cm BW
and 450 cc gel (Dow Corning Corp., Midland, Mich),
which were underfilled and were associated with a sub-
stantial rate of skin wrinkling. Textured silicone gel
implants were used following tissue expansion in the
patient illustrated in Figure 6-43.
Inadequate tissue padding or thin covering tissue is
another very common motif in patients who display wrin-
kles or ripples after a breast reconstruction. Rippling that
results from thin covering tissue is difficult to correct
without supplementing the inadequate covering soft tis-
sue envelope with the addition of a flap. In such cases
transposing a latissimus muscle flap to wrap the implant
Chapter 6
Revision of Implant Breast Reconstruction
287
FIGURE 6-42. (CONTINUED) H–I, At 6-month follow-up,
there is definite improvement (compared with preoperative
appearance in A and B). Patient is pleased with outcome of revi-
sion procedure in terms of increase in projection of breasts.

may be helpful. If this is done, I find that it is helpful to
tack the latissimus muscle to the periphery of the implant
pocket with sutures and place the implant beneath it.
I have had little experience with synthetic tissue sub-
strates such as allogenic dermal grafts11,12 when used for
this purpose, but they may hold promise. In a recent arti-
cle, Baxter11 outlines the use of AlloDerm acellular dermal
grafts (LifeCell Corp., Branchburg, NJ) as an inlay graft to
the superior and inferior aspect of the periprosthetic cap-
sule to improve rippling following a saline implant breast
reconstruction. The series is small, but the results are
encouraging. I suspect that this substrate will have more
widespread use for problems encountered following
implant breast surgery in the future.
At present I believe that adding vascularized tissue to
the periprosthetic capsular space is a far more reliable
way of increasing the tissue padding and decreasing the
possibility of folds in selected cases. Of course such a tech-
nique means an additional major operation, most often
with an additional donor scar, which may also be an aes-
thetic detraction. Because of this, suggesting this option
to an aesthetic patient (i.e., a previous breast augmenta-
tion patient) is almost never done. However, in the
extremely rare instance when it might be an option, it can
be offered with reservation, but the surgeon must explain
thoroughly the additional incisions and possible donor
deformity and obtain the appropriate informed consent.
The use of a TRAM flap to treat recalcitrant capsular con-
tracture in a breast augmentation patient is illustrated in
Chapter 4.
Breast reconstruction patients are more likely to be
accepting of such an intervention, but they too must be
informed of the additional incisions that will result in per-
manent scars that can be unattractive, along with the
other potential risks of such a procedure, including partial
or complete flap loss.
Smooth implants in general show less rippling than
textured implants, and silicone implants show less rip-
pling than saline implants. I often convert a patient from a
textured device to a smooth device of greater dimensions
and volume when performing a reoperative procedure to
address rippling following a previous implant breast
reconstruction. I believe there is significantly less chance
that a smooth silicone device will cause rippling because
of the better fill volume and the more avid capsule that is
generally laid down around the device as part of the
288
Reoperative Plastic Surgery of the Breast
FIGURE 6-43. A, Fold seen in upper pole of both breasts fol-
lowing bilateral breast reconstruction with full-height tissue
expanders and shaped textured silicone gel implants (13.1 cm,
450 cc). B. Folds are accentuated in different postures, and espe-
cially when bending forward.
TABLE 6-1 Etiology of Skin Folds with Implant
Breast Reconstruction
G Underfilled upper pole of implant
G Thin covering or padding tissue
G Textured implant with traction rippling
G Implant–pocket disproportion

Chapter 6
Revision of Implant Breast Reconstruction
289
patient’s natural biologic incorporation of the smooth-
surfaced implant. I often alter the dimensions of the
periprosthetic capsular space with plication sutures as
part of this procedure (see Fig. 6-36).
Many times I have been successful in decreasing the
visibility of ripples and folds by increasing the quantity
and quality of soft tissue padding over the implant and
changing the characteristics of the implant. However,
even when the soft tissue envelope is of adequate thick-
ness (>1.5 cm), ripples or folds from the implant may still
be seen through the skin. I believe that properly fitting the
implant into the periprosthetic capsular space minimizes
this occurrence.
FOLDS FOLLOWING IMPLANT
RECONSTRUCTION—PERIPROSTHETIC
CAPSULAR SPACE–IMPLANT
DISPROPORTION
Disproportions between the implant size and volume and
the volume and dimensions of the periprosthetic capsular
space are often responsible for the appearance of ripples
or folds following implant placement (see Table 6-1).
Indeed the treatment of folds almost always involves
addressing this disproportion, either by placing a larger
implant in terms of dimension or volume or by decreasing
the volume of the previous periprosthetic capsular space
by placing sutures in the capsule to tighten it while plac-
ing a larger implant. As noted earlier, I most often perform
a combination of these maneuvers.
It is my belief that the periprosthetic capsular space
can be altered in a predictable way by suture placement
internally to plicate the capsule (see Fig. 6-36). This
requires removal of the implant for direct visualization of
the capsule. As previously illustrated, this maneuver can
be done to raise the level of the IM fold or to reposition an
implant more medially by closing down the lateral recess
of the periprosthetic capsular space. These alterations
entail suture placement at the base of the periprosthetic
capsule (see Fig. 6-36), where such suture placement
almost always produces a change in the external contour
or visual outline of the breast. Alterations can be subtle or
dramatic, as previously demonstrated for correction of
various asymmetries. However, the volume of the
periprosthetic capsular space can be decreased without
altering the obvious visible dimension or contours of the
breast by placing the sutures away from the base. When
viewed in cross section or sagittal section, such suture
placement is usually in the middle zone of the capsule (see
Fig. 6-36; sutures placed in the middle or equator of the
capsule). This maneuver most often decreases the volume
of the periprosthetic capsular space without altering
external contour or projection of the implanted breast, as
illustrated in the diagram (see Fig. 6-36). Multiple sutures
are usually needed to produce such a correction. The sur-
geon must make sure there is no distortion produced in
the skin contour when placing these sutures.
As sutures are placed close to the dome or the most
anterior aspect of the periprosthetic capsular space, there
tends to be a corresponding decrease in projection of the
implanted breast, producing a slight flatness to the breast
form. In some instances it may be necessary to remove
and replace sutures to achieve the desired capsular tight-
ening while preserving the optimal breast shape in terms
of projection. The first sutures are usually placed with the
implant having been removed; however, it is often possible
to retract the implant with a narrow ribbon or Deaver
retractor to place additional sutures to fine tune the cor-
rection. I prefer to place 3-0 Prolene sutures because they
will not dissolve.
These concepts were used in this patient (Fig. 6-44),
who was dissatisfied with the folds in the upper outer
aspect of her left breast reconstruction following a staged
tissue expansion and textured shaped silicone gel place-
ment. She had undergone the placement of an implant
with a base dimension of 13.9 cm and a gel volume of 540
cc. Note the folds in the upper pole of the left breast
reconstruction (Fig. 6-44A), especially in its outer aspect
(Fig. 6-44B).
The operative plan included two maneuvers. We per-
formed a suture modification of the periprosthetic cap-
sule with slight elevation of the IM fold. The implant was
changed to a smooth-surfaced device with a greater base
dimension, greater volume, and higher profile (14.2 cm,
650 cc, high-profile silicone gel; Fig. 6-44C). The problem
was corrected and the patient shows an excellent appear-
ance of the breast at a 9-month postoperative follow-up
and is very pleased with the results of this reoperative pro-
cedure (Fig. 6-44D,E).
In summary, the correction of ripples and folds in the
setting of breast reconstruction is difficult. When reopera-
tion to treat ripples and folds is undertaken, the surgery
involves at a minimum altering the periprosthetic capsu-
lar space by tightening it and changing the implant with
regard to dimension, volume, surface texture, or all three.
Surgery may also involve providing additional padding
tissue in the form of a flap. The flaps most commonly used
for this purpose are the TRAM flap and the latissimus
dorsi flap.

290
Reoperative Plastic Surgery of the Breast
FIGURE 6-44. A, Skin folds are noted in upper pole of left
breast reconstruction done with shaped textured silicone gel
implant after previous tissue expansion. B, Lateral folds were
especially objectionable to patient. C, She underwent removal of
textured silicone implant (13.9 cm, 540 cc) and had insertion of
smooth-walled high-profile silicone gel implant (14.2 cm, 650
cc). Nine-month follow-up of her appearance on AP (D) and
oblique (E) views shows correction of folds.