Các Vấn Đề Trong Phẫu Thuật Tuyến Vú: Cẩm Nang Sửa Chữa (Repair Manual)

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
572
ANALYSIS O F THE PRO BLEM
On analysis, the patient not only had capsular contracture, but she had a very lim-
ited so t tissue envelope and marked skin de ciency, compared with her contralat-
eral breast. She did not want a patchlike f ap reconstruction and was unwilling to
have a latissimus dorsi f ap, because she was athletic and engaged in outdoor activi-
ties. There ore our plan was to per orm a reverse abdominoplasty with at trans er
(RAFT) to salvage her implant reconstruction.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o her 350 cc implant through an axillary incision
Placement o a 130 cc round silicone implant
Placement o a purse-string suture intradermally (needed or RAFT)
Cephalad advancement o abdominal tissue
Rigottomies to release restrictive vertical abdominal bers that limit tissue ad-
vancement or tissue sliding
Further advancement o suture and abdominal tissue
Fat gra ting between the skin and implant
TECHNIQ UE
The patient’s problem was corrected in one stage. The implant was removed
through a new axillary incision, and a 130 cc round silicone implant was placed.
The original incisions were not reopened, because we planned to gra t at across the
scar and improve its appearance. Adequate at gra ting is not possible i scars are
reopened. Laxity was evident a ter the original implant was replaced by a smaller
one. Room was now available or at gra ts in the tight space between the capsule
and skin.

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A tiny stab incision was made near the clavicle. A purse-string suture was inserted
and threaded intradermally along the caudal arc o upper abdominal tissue to be
advanced cephalad as a RAFT. (This tissue will become the new IMF.) This was
per ormed be ore the Rigottomies were carried out; there ore advancement o the
abdominal f ap was minimal, and the double-bubble de ormity rom the original
IMF was evident.
Extensive Rigottomies were then per ormed to release the old and allow urther
advancement o the abdominal f ap. Rigottomies consist o releasing the scarred tis-
sue with the needle tip by sweeping across the scar bands with sideways pressure.
These maneuvers loosened the advanced apron rom the deeper muscle layer to
better de ne the new IMF and allowed reorientation o the bers to smooth the
old IMF. The double-bubble de ormity was completely eliminated. Percutaneous
Rigottomies created a wound inter ace that allowed the tissues to heal in their new
position.
The crescent-shaped epigastric tissue was mobi-
lized percutaneously using the long, purse-string
intradermal suture, which was advanced via sus-
pension to the clavicle using a bone anchor. The
plane between the implant sca old and the skin
was lled with approximately 350 cc o dilute,
minimally centri uged lipoaspirate. We also gra ted
the epigastric f ap, the axillary hollow, and the up-
per chest

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PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown preoperatively and 10 months postoperatively. Her breast
symmetry and shape are improved. Her volume is increased as a result o the RAFT
procedure, which provides the added bene t o abdominal liposuction and tighten-
ing o the lax abdominal skin apron or improved body contour and a better waist-
line. The patient now has a smaller implant that is approximately one third the size
o the original; it is now well padded with viable at.

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TEACHING PO INTS
The RAFT procedure is a minimally invasive alternative to the transverse rectus ab-
dominis myocutaneous f ap. Laxity is not cut out o the lower abdomen and trans-
erred as an isolated f ap. Instead, the upper abdominal apron is loosened, mobi-
lized, and advanced. Dissection is per ormed percutaneously with Rigottomies and
or placement o the anchor and suture. De nition is provided by advancement o
the long purse-string suture that is suspended rom the clavicle. A 7 cm wide cres-
cent o epigastric tissue is brought into the breast without using an incision, provid-
ing nice de nition to the IMF. Smaller implants with more autologous tissue pad-
ding achieve better, long-term results that are less complication prone and more
natural.
BIBLIO GRAPHY
Bucky LP, Godek CP. Discussion: Baran CN, Celebiog˘lu S, Sensöz O, et al. The behavior o at gra ts
in recipient areas with enhanced vascularity. Plast Reconstr Surg 100:1652, 2002.
Coleman SR, Mazzola RF, eds. Fat Injection: From Filling to Regeneration. St Louis: Quality Medical
Publishing, 2009.
Coleman SR, Saboeiro AP. Fat gra ting to the breast revisited: sa ety and e cacy. Plast Reconstr Surg
119:775-785, 2007.
Delay E. Reconstruction o breast de ormities. In Coleman SR, Mazzola RF, eds. Fat Injection: From
Filling to Regeneration. St Louis: Quality Medical Publishing, 2009.
Delay E. Lipomodeling o the reconstructed breast. In Spear SL, ed. Surgery o the Breast: Principles
and Art, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2011.
Delay E. Correction o partial breast de ormities with the lipomodeling technique. In Kuerer H, ed.
Kuerer’s Breast Surgical Oncology. New York: McGraw-Hill, 2010.
Gusset J, Flageul G, Toussoun G, et al. [Lipomodelling or correction o breast conservative treatment
sequelae. Medicolegal aspects. Expert opinion on ve problematic clinical cases] Ann Chir Plast
Esthet 53:190-198, 2008.
Kurita M, Matsumoto D, Shigeura T, et al. Inf uences o centri ugation on cells and tissues in liposuc-
tion aspirates: optimized centri ugation or lipotrans er and cell isolation. Plast Reconstr Surg
121:1033-1041, 2008.
Missana MC, Laurent I, Barreau L, et al. Autologous at trans er in reconstructive breast surgery: in-
dications, technique, and results. Eur J Surg Oncol 33:685-690, 2007.
Pierre eu-Lagrange AC, Delay E, Guerin N, et al. Radiological evaluation o breasts reconstructed
with lipomodeling. Ann Chir Plast Esthet 51:18-26, 2006.
Rietjens M, De Lorenzi F, Petit JY. Secondary breast reconstruction. In Coleman SR, Mazzola RF, eds.
Fat Injection: From Filling to Regeneration. St Louis: Quality Medical Publishing, 2009.
Rigotti G, Marchi A, Baroni G. Structural at gra ting or the regeneration o irradiated tissue. In
Coleman SR, Mazzola RF, eds. Fat Injection: From Filling to Regeneration. St Louis: Quality
Medical Publishing, 2009.
Spear SE, Wilson HB, Lockwood MD. Fat injection to correct contour de ormities in the reconstructed
breast. Plast Reconstr Surg 116:1300-1305, 2005.
Zocchi ML, Zuliani F. Bicompartmental breast lipostructuring. Aesthetic Plast Surg 32:313-328, 2008.

38b Capsulotomies With ADM After Radiotherapy
Ma u r ic e Y. n a h a bed ia n
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 41-year-old woman was diagnosed with multi ocal, invasive ductal le t breast
cancer. The largest tumor was 2.5 cm in diameter. She was interested in unilateral
mastectomy and immediate reconstruction. Her likelihood o having chemotherapy
and radiotherapy was high. She was otherwise healthy. On physical examination
the patient measured 5 eet 8 inches tall and weighed 130 pounds. Her breasts were
mild to moderate in volume, with grade 2 ptosis. Her abdomen was thin with very
little lipodystrophy.
The surgical plan involved a unilateral mastectomy and sentinel lymph node biopsy,
ollowed by immediate breast reconstruction using a tissue expander and an acellu-
lar dermal matrix (ADM). A 275 cc tissue expander was placed in the partial sub-
muscular position, and the so t tissues were supported with an ADM. The expander
was initially lled to 150 cc. Postoperatively she had no complications and com-
pleted a course o chemotherapy ollowed by radiotherapy.
A ter the completion o radiotherapy, the patient developed progressive tightening
o her skin envelope and capsular contracture.
576

Chapter 38 • Capsular Contracture After Breast Reconstruction

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ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient’s le t breast is tight with moderately indurated skin. Radiotherapy has
caused mild to moderate discoloration and elevation o her IMF by 1 to 2 cm. She
has grade 3 capsular contracture.
ANALYSIS O F THE PRO BLEM
The ndings or this patient are typical a ter radiotherapy in the setting o pros-
thetic devices. Although radiation e ects never completely go away ( brosis and
altered circulation persist), the thermal e ects and super cial burn will improve
over time. Radiotherapy will have adverse e ects on the microvasculature and elas-
ticity o so t tissues. Changes to capillaries and small vessels lead to reduced f ow.
This renders the tissues more prone to in ection and delayed healing. Subsequent
brosis will limit the amount o expansion that can be achieved. With increasing -
brosis, the prosthetic device will o ten times migrate in a cephalad direction. This is
more notable when the device is placed in a submuscular position, compared with a
partial submuscular position. Aggressive expansion a ter radiotherapy can result in
remodeling and concavity o the anterior ribs. Some experimental evidence suggests
that radiation e ects may be decreased in the presence o ADM.
RECOMMENDED SOLUTION TO THE PROBLEM
Device exchange 6 to 12 weeks a ter the completion o radiotherapy
A counterincision along the lateral IMF i needed
A capsulotomy and possible capsulectomy
Placement o an implant

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
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TECHNIQ UE
The exchange was per ormed through the old mastectomy incision, because the so t
tissues were reasonably thick. It was carried out 10 weeks a ter radiotherapy was
completed. The prosthetic space was entered at the junction o the in erior pectora-
lis major muscle and the ADM. The tissue expander was removed. The ADM was
adhered, viable, and revascularized. The le t IMF was 2 cm higher than the right
IMF. An extensive capsulotomy was per ormed superiorly, medially, and in eriorly.
In eriorly the ADM was scored horizontally and vertically to allow the lower pole
to reexpand. The pocket was copiously irrigated with a dilute povidone-iodine so-
lution ollowed by an antibiotic solution. A silicone gel sizer was used to optimally
determine implant size. A 250 cc high pro le silicone gel implant was selected. No
drain was used in this case, but I sometimes place a drain in previously irradiated
patients to reduce the risk o seroma. The skin incision was closed in three layers
using 3-0 absorbable mono lament sutures in the capsular layer, 3-0 absorbable
mono lament sutures in the dermis, and 4-0 absorbable mono lament sutures in
the subcutis. A contralateral mastopexy was per ormed or symmetry.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient had good symmetry 4 months postoperatively.

Chapter 38 • Capsular Contracture After Breast Reconstruction

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Three years postoperatively her right breast had become progressively more ptotic.
Her le t breast was so t but had lost projection.
Five years postoperatively her le t implant was exchanged or a 350 cc contoured
silicone gel device, and the right mastopexy was revised. She has greatly improved
symmetry and is pleased with her result.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
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TEACHING PO INTS
The timing o optimal intervention or device exchange is debatable. Some believe
that the tissue expander should be exchanged or a permanent implant 6 to
12 months a ter radiotherapy, while others believe that it should be exchanged
6 to 12 weeks a ter radiotherapy. My pre erence is 6 to 12 weeks and is based on
per orming secondary procedures during the subacute phase o radiation injury
rather than the chronic phase o radiation injury. It is postulated that the tissues
are more amenable to modi cation 6 to 12 weeks a ter radiotherapy, compared
with the interval o 6 to 12 months when the tissues become less amenable to
modi cation.
Optimal incision placement is based on so t tissue thickness. Sometimes the apical
skin o the breast becomes thin and atrophic a ter radiation. I the irradiated skin
has adequate thickness, the previous incision is reincised. I the old incision is thin,
an in ramammary counterincision is made. Reincision o a thin scar can result in
postoperative incisional dehiscence. A capsulotomy is usually per ormed superiorly,
medially, and in eriorly. A capsulectomy is needed i the capsule is too thick. Ideally
a contoured silicone gel implant is used, because it will provide better upper and
lower pole contour. The device should be properly aligned in the pocket to prevent
a rotation de ormity. A drain is usually placed when contoured devices are used. A
round silicone gel implant may also be used and will usually provide excellent re-
sults but can sometimes result in an upper pole de ciency or scalloping.
Recurrent capsular contracture can occur in patients who have radiotherapy. For-
tunately this patient’s irradiated breast remained so t. This may have resulted rom
the presence o an ADM or the aggressive massage therapy that is recommended in
the setting o prosthetic devices and radiation. The nonirradiated breast typically
demonstrates more ptosis than the irradiated breast over time. This can always be
adjusted with additional surgical procedures.
BIBLIO GRAPHY
Ho G, Lee DJ. Long-term ollow-up o capsular contracture rates in implant-based breast reconstruc-
tion using acellular dermal matrix. Abstract accepted at the Annual Scienti c Meeting o the
Southern Cali ornia Chapter o the American College o Surgeons, Santa Barbara, CA, Jan 2011.
Nahabedian MY. AlloDerm per ormance in the setting o prosthetic breast surgery, in ection, and ir-
radiation. Plast Reconstr Surg 124:1743-1753, 2009.
Stump A, Holton LH III, Connor J, et al. The use o acellular dermal matrix to prevent capsule orma-
tion around implants in a primate model. Plast Reconstr Surg 124:82-91, 2009.

38c Explantation, Capsulectomy, and Reconstruction
After Silicone Implant Rupture and Chronic Hematoma
n ea l h a n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 66-year-old woman had a long, complicated history o breast problems. She
had a positive amily history or breast cancer, and a breast biopsy revealed atypi-
cal ductal hyperplasia. A prophylactic mastectomy was advised. In her late thirties
she had bilateral subcutaneous mastectomies with immediate breast reconstruction
using submuscular double lumen (gel/saline) implants. The patient subsequently
developed capsular contracture and had a capsulotomy with implant removal and
replacement. She had recurrent contracture and underwent another corrective oper-
ation in 1988, consisting o a capsulotomy and insertion o Inamed (Santa Barbara,
CA) 365 cc round textured (Biocell) silicone gel implants into the same submuscu-
lar pocket. No additional procedures were per ormed.
The patient rst consulted with me in 2004. At that time she presented with an
acute increase in the size o her le t breast, with no history o trauma. Physical ex-
amination con rmed rmness, tenderness, and a moderate increase in the size o
her le t breast, but no signs o inf ammation or in ection. No ecchymoses were
noted. Surgical exploration and drainage o a presumed seroma or hematoma were
recommended. However, the patient did not return or treatment.
She returned 3 years later. Her le t breast was much larger and rmer than her right
side (at least 300 to 400 cc greater in volume). Again, surgical exploration was rec-
ommended to drain a presumed chronic seroma or hematoma. Radiologic imaging
studies were not ordered at that time, because it seemed unlikely that the result o
radiologic examination would change the recommendation or surgical interven-
tion. The patient again delayed de nitive treatment.
The patient returned 5 years later at age 66. She had no treatment o her breast
during this interval. Her symptoms remained essentially unchanged. However, in a
recent abdominal CT scan or an unrelated problem, it was incidentally noted that
her le t breast implant was ruptured.
581

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
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ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
Physical examination con rms massive enlargement o the patient’s le t breast. It is
rm on palpation but nontender, with no erythema or warmth. Her axillary lymph
nodes are not enlarged. Her right breast has Baker grade III capsular contracture.
ANALYSIS O F THE PRO BLEM
The patient presented with chronic, massive, unilateral breast enlargement a ter
bilateral subcutaneous mastectomies and submuscular implant reconstruction. She
had no history o trauma or signs or symptoms o in ection. A recent CT scan re-
vealed rupture o her le t breast implant. The cause o the chronic (almost 8 years)
enlargement o her breast was indeterminate. Silicone implant rupture with intra-
capsular or extracapsular spread o silicone is not typically associated with signi -
cant enlargement o the breast. However, in view o recent reports o anaplastic
large cell lymphoma (ALCL) in association with late seromas and the CT evidence
o silicone implant rupture, the patient nally agreed to proceed with exploration
o the breast. Surgery was planned with the goal o de nitive treatment o the un-
derlying cause o the unilateral breast swelling and reconstruction in the same pro-
cedure. Simultaneous contralateral explantation, capsulectomy, and reconstruction
with a new silicone gel implant were anticipated.

Chapter 38 • Capsular Contracture After Breast Reconstruction

583
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the ruptured le t implant and all ree silicone gel
Le t total capsulectomy
Evacuation o f uid such as blood, serum, and clots
Right explantation and capsulectomy
Bilateral breast reconstruction with shaped, orm-stable silicone gel implants
Maneuvers to control pocket size and prevent shaped implant rotation
TECHNIQ UE
The patient’s previous in ramammary scar was excised. The wound was deepened
with cautery and the capsule opened. Hemosiderin-stained f uid, organized hema-
toma (old clotted blood), and ree silicone drained immediately rom the ruptured
implant. The gel in the early second-generation implant was relatively cohesive, but
the shell was torn widely open, with spillage o virtually all o the silicone. Massive
amounts o old, clotted blood were expressed rom the pocket.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
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The explanted shell and all ree silicone were removed, and most o the clotted
blood was evacuated. Some o the blood clots were adherent to the thickened cap-
sule.
The pocket was pulse-lavaged with 3 L o bacitracin antibiotic solution to remove
residual blood and ree silicone. The thickened, hemosiderin-stained capsule was
then excised in its entirety. Electrocautery dissection was used to remove the cap-
sule en bloc. The breast is shown a ter removal o the ruptured implant, along with
all ree silicone gel, liquid, clotted blood, and the entire periprosthetic capsule.

Chapter 38 • Capsular Contracture After Breast Reconstruction

585
On the contralateral breast, the previous in ramammary scar was excised. The
wound was deepened though the anterior capsule. Once the capsule was opened,
extensive gel bleed with pooling o ree silicone around the periphery o the implant
was apparent. As the implant was removed, leaking gel herniated through a rent in
the shell. A total capsulectomy was per ormed to remove all residual silicone that
had impregnated the capsule and to reduce the risk o recurrent contracture.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
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During the preoperative consultation, the patient had tentatively decided on recon-
struction with a shaped implant in the range o 350 to 425 cc. The size depended
on the device that best t the so t tissue envelope and achieved the desired aesthetic
result. An inf atable sizer was inserted into the pocket and lled with saline until
volume and shape were satis actory. A 425 cc shaped Classic Base implant (Sientra;
Santa Barbara, CA) was chosen. Two 15 Fr round f uted drains were placed in the
pocket, one medial to the implant and one lateral to the implant. The shaped device
was care ully oriented to align the midline mark on the in erior pole o the prosthe-
sis at the 6 o’clock position. To urther ensure that the shaped implant will not ro-
tate in the relatively large pocket, Tisseel brin glue was sprayed between the lateral
chest wall and the adjacent overlying skin f ap. This was done to eradicate the po-
tential space and promote adhesion o the two tissue sur aces.

Chapter 38 • Capsular Contracture After Breast Reconstruction

587
On the le t side, two 15 Fr round f uted drains were placed in the pocket in simi-
lar ashion. An identical, shaped implant was selected or insertion, rinsed in dilute
betadine to reduce the risk o bacterial bio lm ormation, and care ully inserted
into the submuscular pocket. Care was taken to properly orient the implant. Tisseel
brin sealant was sprayed both medially and laterally, between the skin f aps and
the adjacent chest wall, to encourage adhesion o the f aps and control the pocket
perimeter. Firm manual compression was applied laterally to ensure adherence o
the f ap to the adjacent chest wall and closure o the large potential space result-
ing rom the aggressive capsulectomy. The patient’s postoperative course was unre-
markable. Her drains were removed 6 days a ter surgery.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
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PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 6 months a ter the revision surgery. She is very satis ed with
the result. The massive f uid accumulation around the le t mammary implant is suc-
cess ully drained, and capsular contracture is corrected. The breasts have accept-
able volume, contour, and symmetry. The shaped implant has helped to provide a
more natural-appearing silhouette.

Chapter 38 • Capsular Contracture After Breast Reconstruction

589
TEACHING PO INTS
This bilateral subcutaneous mastectomy patient had a wide range o complications
a ter implant reconstruction. She had several episodes o capsular contracture that
were treated with conventional capsulotomy and implant replacement. Despite ap-
propriate treatment, she developed recurrent contracture. For unknown reasons,
the patient later had spontaneous hemorrhage into her le t breast or which she re-
used treatment or several years. Over time, the hematoma organized into a semi-
solid, caseous accumulation within the thickened capsule. At some point, the le t
implant ruptured and caused intracapsular leakage o silicone gel. On the right side,
she developed Baker grade III contracture and had extensive gel bleed and implant
rupture. She “ elt relatively well” throughout the course o these events and was re-
luctant to have surgical intervention until a CT scan revealed that her le t implant
had ruptured and caused intracapsular silicone leakage.
The case encompassed a number o adverse outcomes that individually or in com-
bination required treatment. Massive enlargement o a reconstructed breast years
a ter implantation is usually the result o a hematoma. Sometimes a speci c trauma
is the cause. (A rm hug, a compression mammogram, or a closed capsulotomy can
cause bleeding around the prosthesis.) O ten, as in this case, no antecedent event
is identi ed. I a hematoma is suspected, surgical drainage should be undertaken.
Late seromas are another possible cause o delayed breast enlargement. O ten such
seromas are associated with in ection, although it sometimes is di cult to culture
organisms rom the periprosthetic f uid. I a seroma (with or without in ection) is
suspected, antibiotic therapy should be started empirically and surgical drainage
considered, depending on the clinical response to antibiotics. In recent years several
cases o late-onset f uid accumulation have been associated with ALCL. For this
reason alone, patients who present with delayed onset seromas that do not resolve
relatively quickly should strongly be urged to proceed with surgical drainage and
appropriate cytologic studies.
All o the patient’s problems were treated with a single operation that removed the
ruptured and leaking implants, drained the massive, chronic hematoma, corrected
contracture with total capsulectomy, and achieved an aesthetic reconstruction with
shaped, orm stable implants. Because the pockets on each side were quite large
a ter total capsulectomy, it was necessary to take steps to ensure that the shaped
implant did not rotate. This was done using Tisseel brin sealant as an adjunc-
tive measure, along with suction drains to promote closure o the redundant space
around the implants.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
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BIBLIO GRAPHY
Alobeid B, Sevilla DW, El-Tamer MB, et al. Aggressive presentation o breast implant-associated
ALK-1 negative anaplastic large cell lymphoma with bilateral axillary lymph node involvement.
Leuk Lymphoma 50:831-833, 2009.
Collins JB, Verheyden CN. Incidence o breast hematoma a ter placement o breast prostheses. Plast
Reconstr Surg 129:413e-420e, 2012.
Daw JL, Lewis VL, Smith JW. Chronic expanding hematoma within a periprosthetic breast capsule.
Plast Reconstr Surg 97:1469-1472, 1996.
de Jong D, Vasmel WL, de Boer JP, et al. Anaplastic large-cell lymphoma in women with breast im-
plants. JAMA 300:2030-2035, 2008.
Fodor L, Moscona R. Late post-traumatic intracapsular seroma a ter breast augmentation. J Plast Re-
constr Aesthet Surg 62:e609-e610, 2009.
Mooney E, Loh C, Pu LL; ASPS/PSEF Technology Assessment Committee. The use o brin glue in
plastic surgery. Plast Reconstr Surg 124:989-992, 2009.
Rasko Y, Saint-Cyr M, Peng Y. Spontaneous hematoma o the breast 30 years a ter augmentation.
Plast Reconstr Surg 126:41e-42e, 2010.

C h a p t e r 39
IMPLANT AND EXPANDER
MALPOSITION
39a Secondary Expansion With Implant Replacement
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 42-year-old woman had a previous right breast reconstruction with a tissue
expander and implant. Her initial complaint was that the implant was too high on
her chest, her NAC was in the wrong location, and the reconstructed breast was
rm. (This was a result o the Baker III capsule.) She did not undergo radiotherapy.
The patient was in good health on physical examination.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The most obvious components o the patient’s asymmetry are her elevated right
IMF and the abnormally high reconstructed NAC on the right side. The original
mastectomy scar extends obliquely across the reconstructed mound, rom the right
axilla toward the medial breast. The patient’s right anterior axillary old is absent
because o her original axillary dissection. The tissues are so t and pliable on the
reconstructed side. Her le t breast is nonptotic and o moderate size. Her chest wall
is symmetrical.
591

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ANALYSIS O F THE PRO BLEM
This patient’s presentation is relatively common a ter expander-implant reconstruc-
tions. Capsular contracture occurred over time and caused the implant to rise su-
periorly with loss o the IMF, creating a round, spherical nonptotic reconstructed
breast. As a secondary phenomenon, the reconstructed NAC migrated superiorly
to an abnormal location. The breast became a tight, round hemisphere, contribut-
ing to the overall asymmetry. A critical part o a patient’s analysis is to determine
whether she will require new autologous tissue or whether reexpansion o the origi-
nal breast mound can correct the de ormity. Because her le t breast was o moder-
ate size, limited expansion would be necessary to achieve symmetry.
RECOMMENDED SOLUTION TO THE PROBLEM
Reexpansion o the right breast
Placement o a new implant
Repositioning o the NAC
TECHNIQ UE
The rst step o this two-part reconstruction consisted o removal o the right im-
plant, ollowed by a total capsulectomy and placement o a 700 cc anatomic tissue
expander. Precise placement along the new IMF location was determined by com-
parison with the patient’s le t IMF. Over the next several weeks, her right breast
mound was reexpanded, ensuring adequate volume and proper location o the
new IMF.

Chapter 39 • Implant and Expander Malposition

593
Once expansion was complete, the patient was returned to the operation room and
the second step o the reconstruction was carried out. Sizers were used to determine
the appropriate-size implant, which was placed in the newly reexpanded pocket. At
the same time, her previous NAC reconstruction was excised in a ull-thickness skin
gra t and reapplied to the new location on the breast mound. This required primary
closure o the donor NAC site, resulting in a transverse scar several centimeters
above the new nipple placement.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
A ter the rst stage o the patient’s reconstruction, the photos demonstrated proper
positioning o the new IMF and creation o an appropriate base diameter o the
new reconstructed mound. In this situation, signi cant overexpansion was per-
ormed or reexpansion o the lower pole o the new breast mound. The early post-
operative photos showed appropriate symmetry between the newly reconstructed
breast mound and the le t breast, and appropriate placement o the repositioned
NAC on the right.
At 2-year ollow-up the patient’s right breast is so t, and her new IMF is in an ex-
cellent position. However, the trans er o the previously reconstructed NAC on her
right side shows limited success because o nipple projection loss.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
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TEACHING PO INTS
When the nonoperated breast is o limited size, reexpansion can be a use ul tool. A
new IMF is best obtained with expansion versus implant replacement alone. I nip-
ple malposition is signi cant, removal as a composite gra t and replantation may be
required.
BIBLIO GRAPHY
Baschnagel AM, Shah C, Wilkinson JB, et al. Failure rate and cosmesis o immediate tissue expander/
implant breast reconstruction a ter postmastectomy irradiation. Clin Breast Cancer 12:428-432,
2012.
Butler CE, Kronowitz SJ. Discussion: Immediate tissue expander/implant breast reconstruction a ter
salvage mastectomy or cancer recurrence ollowing lumpectomy/irradiation. Plast Reconstr Surg
129:351-353, 2012.
Cordeiro PG, Snell L, Heerdt A, et al. Immediate tissue expander/implant breast reconstruction a ter
salvage mastectomy or cancer recurrence ollowing lumpectomy/irradiation. Plast Reconstr Surg
129:341-350, 2012.
Peled AW, Stover AC, Foster RD, et al. Long-term reconstructive outcomes a ter expander-implant
breast reconstruction with serious in ectious or wound-healing complications. Ann Plast Surg
68:369-373, 2012.
Reish RG, Damjanovic B, Austen WG Jr, et al. In ection ollowing implant-based reconstruction in
1952 consecutive breast reconstructions: salvage rates and predictors o success. Plast Reconstr
Surg 131:1223-1230, 2013.
Scuderi N, Al ano C, Campus GV, Rubino C, Chiummariello S, Puddu A, Mazzocchi M. Multicenter
study on breast reconstruction outcome using Becker implants. Aesthetic Plast Surg 35:66-72, 2011.
Shestak KC. Acellular dermal matrix inlays to correct signi cant implant malposition in patients with
compromised local tissues. Aesthet Surg J 31(7 Suppl):85S-94S, 2011.
Slavin SA, Lin SJ. The use o acellular dermal matrices in revisional breast reconstruction. Plast Recon-
str Surg 130(5 Suppl 2):70S-85S, 2012.
Strock LL. Two-stage expander implant reconstruction: recent experience. Plast Reconstr Surg
124:1429-1436, 2009.
Initial presentation
Expander in place
IMF lowered
Smaller shaped implant
in place

39b Secondary Inframammary Fold Correction During
Expander Removal
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This patient had bilateral mastectomies and immediate insertion o tissue expand-
ers. She saw her original physician several times or expansion. She was concerned
about the higher position o the le t tissue expander and sought consultation with
another physician or this problem.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
When seen in consultation, the patient has reasonably good expansion on her right
side with a volume o 360 cc. However, the le t expander is not only too high, but it
has migrated laterally and upward into the axilla and toward the clavicle. The pa-
tient has healthy so t tissues, no radiation, and does not require chemotherapy be-
cause o her cancer status. She has no chest wall de ormities.
595

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
596
ANALYSIS O F THE PRO BLEM
The le t expander was inserted too high at the time o the immediate bilateral
breast reconstruction. Even in the most experienced hands, this can happen or sev-
eral reasons. The mastectomies themselves may be asymmetrical, depending on the
location o the tumor. The amount o undermined f ap can be asymmetrical, mak-
ing it di cult or the plastic surgeon to establish symmetry. In this case, however,
the submuscular pockets were not made symmetrically, and the lower pole dissec-
tion on the le t side was inadequate. The chances o these problems occurring are
minimized i the patient is placed in an upright position intraoperatively while sub-
muscular sizers are inserted.
Physicians have two treatment options. The rst is to reposition the expander at
this time, or the second is to lower the old when permanent implants are placed.
For patients who will accept relatively small implants, the higher expander can
be removed intraoperatively and an implant inserted in the same operation. The
proposed lower portion o the breast where the implant will be placed, is not ex-
panded. There ore a large implant will compress and distort this tissue. A ter a dis-
cussion with the patient, she chose to avoid an additional operation. Although she
understood that it might not be success ul, she pre erred to have the old lowered at
the time o permanent implant placement.
RECOMMENDED SOLUTION TO THE PROBLEM
Opening o a portion o the previous mastectomy incisions
Removal o the expanders
Excision o an area o the lower capsule o the le t breast
Scoring o the so t tissue o the le t breast in a radial manner
Capsulotomy on the le t side
Placement o sizers
Placement o implants
Reconstruction o the NACs

Chapter 39 • Implant and Expander Malposition

597
TECHNIQ UE
While the patient was in the holding area be ore surgery, the tissue expanders were
def ated to determine the volume and old location required or symmetry. The vol-
ume remaining in the expanders will be evaluated intraoperatively to help with
implant selection. In the OR, a portion o the previous mastectomy incisions were
opened, and the expanders were removed. On the patient’s le t side, multiple radial
scorings were made to lower the IMF. In addition, a capsulotomy was per ormed to
release the so t tissue in this area because o inadequate expansion. On the patient’s
right side no adjustments were necessary. The patient was placed in an upright posi-
tion with temporary sizers in place, and old symmetry was assessed.
The permanent implants were inserted, the incisions closed, and NACs marked. The
nipples were reconstructed using a standard skate f ap technique.
Capsule
excised
Radial
scoring
IMF

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
598
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient has good long-term results with symmetry o her IMFs and volume.
The location o the le t IMF is maintained.

Chapter 39 • Implant and Expander Malposition

599
TEACHING PO INTS
I the treatment goal in an expanded patient is to lower the IMF and place an im-
plant in one stage, then the device needs to be conservative in size. On the other
hand, i a patient wants to continue expansion and have a signi cant increase in
size, then it is better to replace the expander in its appropriate position and con-
tinue expansion. Permanent implants are then placed in a third stage. Implants o
substantial size that are placed without expansion o the lower pole become com-
pressed and distorted, leading to an unsatis actory result.
BIBLIO GRAPHY
Baschnagel AM, Shah C, Wilkinson JB, et al. Failure rate and cosmesis o immediate tissue expander/
implant breast reconstruction a ter postmastectomy irradiation. Clin Breast Cancer 12:428-432,
2012.
Butler CE, Kronowitz SJ. Discussion: Immediate tissue expander/implant breast reconstruction a ter
salvage mastectomy or cancer recurrence ollowing lumpectomy/irradiation. Plast Reconstr Surg
129:351-353, 2012.
Cordeiro PG, Snell L, Heerdt A, et al. Immediate tissue expander/implant breast reconstruction a ter
salvage mastectomy or cancer recurrence ollowing lumpectomy/irradiation. Plast Reconstr Surg
129:341-350, 2012.
Peled AW, Stover AC, Foster RD, et al. Long-term reconstructive outcomes a ter expander-implant
breast reconstruction with serious in ectious or wound-healing complications. Ann Plast Surg
68:369-373, 2012.
Reish RG, Damjanovic B, Austen WG Jr, et al. In ection ollowing implant-based reconstruction in
1952 consecutive breast reconstructions: salvage rates and predictors o success. Plast Reconstr
Surg 131:1223-1230, 2013.
Scuderi N, Al ano C, Campus GV, Rubino C, Chiummariello S, Puddu A, Mazzocchi M. Multicenter
study on breast reconstruction outcome using Becker implants. Aesthetic Plast Surg 35:66-72,
2011.
Shestak KC. Acellular dermal matrix inlays to correct signi cant implant malposition in patients with
compromised local tissues. Aesthet Surg J 31(7 Suppl):85S-94S, 2011.
Slavin SA, Lin SJ. The use o acellular dermal matrices in revisional breast reconstruction. Plast Recon-
str Surg 130(5 Suppl 2):70S-85S, 2012.
Strock LL. Two-stage expander implant reconstruction: recent experience. Plast Reconstr Surg
124:1429-1436, 2009.

39c Bilateral TRAM Flaps Combined With Expander-
Implants
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This patient had a previous bilateral breast reconstruction with tissue expanders,
ollowed by insertion o permanent implants. She was dissatis ed with the shape,
contour, and volume o her breasts and presented or evaluation 2 years a ter the
original surgery. One breast was treated or cancer and the other was removed pro-
phylactically. The reconstruction used muscle alone without acellular dermal ma-
trix (ADM). The patient did not have nipple-areolar reconstruction a ter the per-
manent implants were placed. She reported that no problems occurred during the
expansion phase. Her complaints were asymmetry o the IMFs with the le t side
being slightly higher, lack o ullness and projection, and inadequate volume. She
desired autologous reconstruction but knew that this might not be possible because
she was thin.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has well-healed mastectomy scars that traverse the middle o the recon-
structed mounds. Her implants are relatively small, very tight, and elevated, and
her breasts have minimal projection. The IMFs are high, with the le t old slightly
higher than the right old. She has intact anterior axillary olds. The upper hal o
600

Chapter 39 • Implant and Expander Malposition

601
each reconstructed breast mound has the same i not slightly more projection than
the lower hal , giving her breasts an arti cial contour. Superior pole ullness is ex-
cessive. Examination o the abdomen reveals redundant skin and abundant so t tis-
sue rom multiple pregnancies.
ANALYSIS O F THE PRO BLEM
Many patients who have tissue expander breast reconstruction have limited skin
and so t tissue a ter a mastectomy, resulting in a relatively small size o the recon-
structed breast. Skin laxity and the degree to which tissues will stretch vary greatly
rom patient to patient. Be ore the advent o acellular dermis, the decreased capac-
ity o muscle to expand was sometimes a hindrance. These two actors, limited tis-
sue and limited expansion, resulted in round, high-riding, relatively small breasts,
as in this patient. A normal breast should have a teardrop shape with maximal pro-
jection in the lower pole o the breast mound.
Another important problem in this patient was her high, transverse mastectomy
scars. The use o autologous tissue and placement o new skin at the level o the
scars was not the solution. The tissue needed to be used to create a new, lower IMF
and increase volume in the lower pole relative to the upper pole. Thus a decision
was made to ignore the original mastectomy scar and create a new transverse inci-
sion at the site o the new IMF. This raised the concern o using a narrow bipedicle
f ap based medially or laterally. It was essential that the f ap remained attached to
the underlying muscle or additional blood f ow.
Finally, this patient had inadequate abdominal tissue volume to create a su cient
mound using transverse rectus abdominis myocutaneous (TRAM) f aps. The solu-
tion was the addition o tissue expanders to the autologous reconstruction.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the implants
Development o bilateral TRAM f aps
Insetting o the TRAM skin islands to create new IMFs (The superior margins
o the f ap are below the current mastectomy scars, whereas the in erior margins
are the incision along the new IMF.)
Preservation o the bipedicle transverse f aps’ attachments to underlying muscle
Insertion o tissue expanders deep to the TRAM f aps
Placement o permanent implants
Creation o NACs

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
602
TECHNIQ UE
The original implants were removed through new in ramammary incisions, which
were marked with the patient in an upright position. These transverse incisions
were actually made on the upper abdominal skin, because the expanded breast
mounds were positioned high on the chest. Bilateral TRAM f aps were raised and
inset ipsilaterally. Each f ap was rotated 90 degrees on insertion so that the in erior
edge o the f ap created the new IMF. The skin island was trimmed, creating a sym-
metrical ellipse with the deepithelialized, lateral portion o the f ap inset superiorly
beneath the upper pole o the breast. The original mastectomy scar was le t intact.
The pectoralis muscle rom the original reconstruction remained attached to the
overlying skin to enhance blood supply. Be ore the f ap was completely inset, an
expander was inserted deep to the TRAM f ap. The same procedure was per ormed
on the opposite breast. Postoperatively the patient did well.
New IMF
incision
TRAM flap
skin island
rotated into
lower pole
Rectus incision
Buried
deepithelialized
tissue
Skin flap
forming new
lower pole

Chapter 39 • Implant and Expander Malposition

603
At 5 months permanent implants were placed, and NACs were created using skate
f aps and ull-thickness skin gra ts obtained rom her lateral abdominal scars.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The nal contour is a signi cant improvement. The major drawback to this solu-
tion is the creation o two sets o transverse scars. The upper scars are rom the
original mastectomy. These were le t untouched in the reconstruction. The lower
scars are the inset sites o the TRAM f aps. With the nipple-areolar reconstruction
completed, the original mastectomy scars, which are slightly lowered rom the ex-
pansion, are less noticeable. Whether a TRAM f ap or a latissimus dorsi f ap had

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
604
been used, reopening o the mastectomy scars and insetting o the f aps in the mid-
dle o the breast mound would not result in the desired teardrop shape with greater
projection in the lower pole. Placement o the f ap at the level o the new IMF was
the best compromise.
TEACHING PO INTS
With the use o ADMs, ewer patients will have the problem o inadequate tissue
expansion a ter mastectomy. However, in patients who have very limited skin that
resists expansion, an ADM may not be adequate. The most critical component in
this patient’s revision was the creation o new IMFs with TRAM f ap skin islands.
Attempts at reexpansion in this patient were unlikely to succeed or several reasons.
First, it can result in a double-bubble or inadequate volume. Second, because her
implants were so high on her chest wall, lowering o the current old would most
likely lead to a hemispherical mound as opposed to the teardrop shape achieved
with the TRAM f aps.
BIBLIO GRAPHY
Levine SM, Patel N, Disa JJ. Outcomes o delayed abdominal-based autologous reconstruction versus
latissimus dorsi f ap plus implant reconstruction in previously irradiated patients. Ann Plast Surg
69:380-382, 2012.
Rabey NG, Lie KH, Kumiponjera D, et al. Salvage o ailed prosthetic breast reconstructions by autol-
ogous conversion with ree tissue trans ers. Eplasty 13:e32, 2013.
Tadiparthi S, Staley H, Collis N, et al. An analysis o the motivating and risk actors or conversion
rom implant-based to total autologous breast reconstruction. Plast Reconstr Surg 132:23-32,
2013.

40a Two-Stage Reconstruction Using Local Flaps
Al ber t Lo sk en
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 54-year-old obese woman had right breast cancer and macromastia. She was
scheduled or a right mastectomy and expander reconstruction. It was thought that
given her body habitus an abdominal-based ap would have a high risk o potential
donor site morbidity. Another potential reconstructive option discussed was the la-
tissimus dorsi ap; however, the patient was not interested in moving muscle rom
her back and wanted the simplest possible procedure. She understood the disadvan-
tages o implant reconstruction in patients with macromastia. A skin-reducing mas-
tectomy was per ormed, along with a sentinel lymph node biopsy. Her reconstruc-
tion involved the use o a tissue expander placed beneath the pectoralis muscle and
expanded to 400 cc.
c h APt e r 4 0
FAILED EXPANDER/IMPLANT
RECONSTRUCTION
605

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
606
The lower pole was covered with a vascularized deepithelialized ap rom the re-
tained lower pole mastectomy ap. This was then sutured to the pectoralis muscle,
and the skin was closed under no tension. A le t breast reduction was per ormed,
with removal o 1083 g o tissue.
Although she was a nonsmoker with healthy-appearing skin aps at the time o
surgery, she had compromised lateral mastectomy skin aps at her postoperative
visit.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
ANALYSIS O F THE PRO BLEM
This patient had ull-thickness necrosis o her mastectomy skin aps a ter expander
reconstruction. The concern was the presence o a tissue expander beneath the ne-
crotic skin; however, it was covered by the pectoralis major muscle and a vascular-
ized lower pole ap. Her shape was otherwise preserved, and the area o necrosis
was demarcated and stabilized. The necrosis was dry with no evidence o in ec-
tion. The area was too large to heal secondarily. The goal was to allow the ex-
pander pocket to mature and heal so that the only variable to treat was the necrotic
skin envelope. This could potentially have been prevented by using intraoperative
Spy angiography (Novadaq Technologies, Inc., Bonita Springs, FL) and discard-
ing poorly per used tissue, preserving lower mastectomy skin to replace the area
debrided.
The patient has ull-thickness necrosis o the lateral
mastectomy skin ap, measuring about 6 by 7 cm.
The closure was not tight; there ore uid was not
removed rom the expander. There is no evidence o
in ection. The remaining aps are viable, and inci-
sions are otherwise healing well. Skin necrosis some-
times occurs when a Wise pattern skin-reducing mas-
tectomy is per ormed, because the aps are o ten
relatively long.

Chapter 40 • Failed Expander/Implant Reconstruction

607
RECOMMENDED SOLUTION TO THE PROBLEM
Local wound care or a ew weeks
Aggressive debridement and coverage by a local skin ap
Removal o the expander
Implant placement at a later procedure with IMF revision
TECHNIQ UE
The patient was taken to the operating room or sharp debridement o the necrotic
skin. Healthy granulating tissue was noted a ter debridement, with no communica-
tion with the expander pocket. The options at this point included a skin gra t, lo-
cal asciocutaneous ap, or latissimus dorsi ap with a skin island. We elected to
per orm a thoracoepigastric ap rom the patient’s upper lateral abdomen. The ap
was designed wide enough to cover the de ect, but not so wide that the donor site
could not be closed primarily. It was elevated rom lateral to medial in the sub as-
cial plane. Medial per orators were preserved and enough dissection was per ormed
to allow easy rotation into the de ect. The donor site was closed within the IMF.
The ascia was secured to the chest wall at the level o the old to reduce the poten-
tial or descent. The ap was then inset under minimal tension.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
608
Once healed, expansion was completed. The patient returned to the operating room
2 months later or replacement o her tissue expander with a 400 cc moderate pro-
f le gel implant, and revision o the contour de ormity at the level o her IMF. The
pedicle to the ap was essentially divided and the IMF revised. She is shown 1 year
a ter her mastectomy. Nipple-areolar reconstruction was subsequently per ormed.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 1 year a ter completion o nipple-areolar reconstruction. Her
shape is preserved, and she has adequate and stable so t tissue coverage o her im-
plant. She has very good symmetry with the contralateral, reduced breast.

Chapter 40 • Failed Expander/Implant Reconstruction

609
TEACHING PO INTS
It is important to treat large areas o mastectomy skin necrosis with aggressive de-
bridement and coverage with well-vascularized tissue when possible. This will elim-
inate the potential or healing by contracture, especially in the lower pole and in
prosthetic-based reconstructions. Although a skin gra t could have provided good
coverage in this patient, the long-term durability, color match, and maintenance o
shape would have been less avorable.
Division o the pedicle was possible in this patient, given the vascularized nature o
her wound bed and the revascularization o her ap at the skin edges once healed.
The minimal amount o time or division o the pedicle would be approximately
1 month in a ap o this size.
BIBLIO GRAPHY
Losken A, Collins BA, Carlson GW. Dual plane prosthetic reconstructing using the modif ed Wise
pattern mastectomy and asciocutaneous ap in women with macromastia. Plast Reconstr Surg
126:732-738, 2010.
Moyer HR, Losken A. Predicting mastectomy skin ap necrosis with indocyanine green angiography:
the gray area def ned. Plast Reconstr Surg 129:1043-1048, 2012.
Patel KM, Hill LM, Gatti ME, et al. Management o massive mastectomy skin necrosis ollowing au-
tologous breast reconstruction. Ann Plast Surg 69:139-144, 2012.t

40b Reconstruction Using Local Tissue
n ea l h a n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 32-year-old Hispanic woman presented with an extruded implant and a large,
open wound on her right breast. Her history o prior breast treatment was com-
plicated. Two years previously she had a combined breast augmentation and ab-
dominoplasty in Mexicali, Mexico. Postoperatively she developed what was char-
acterized as a severe in ection o her right breast, necessitating explantation. She
subsequently returned home to Cali ornia. Sometime later the patient was seen by
a local plastic surgeon, who inserted a tissue expander. A ew months later the ex-
pander became in ected and was removed. About 4 months later another expander
was placed and in ated to a volume o 600 cc over a period o 14 weeks. The ex-
pander was removed, and new silicone gel implants were inserted bilaterally.
Within 2 months the patient developed another in ection o her right breast,
which caused wound separation with exposure o the prosthesis. The implant was
removed 3 months be ore she presented to my o f ce or treatment.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient is a tall, slightly obese Hispanic woman. She has had a bilateral aug-
mentation mammaplasty, and her right implant is extruded. The right breast is mis-
shapen, with an oblique, cle tlike central depression. Her nipple is absent, and her
areola is severely distorted and retracted, and is adhered to the deep structures. A
2 by 3 cm f stulous opening connects the scarred areola with the underlying chest
wall, which is lined with a mature scar tissue capsule. The ap edges are not un-
dermined, and no signs o in ection are evident. On the le t side a large silicone
gel implant o approximately 600 cc is in place. She has a well-healed periareolar
scar along the medial border o her areola that extends rom the 6 o’clock position
to the 12 o’clock position. A 1 cm depressed, retracted area is in the lower inner
quadrant o her le t breast. The breast is so t (Baker grade I).
610

Chapter 40 • Failed Expander/Implant Reconstruction

611
ANALYSIS O F THE PRO BLEM
The patient presented with severe breast de ormity a ter multiple prior in ections
that involved implants and tissue expanders. At the time o presentation, she had a
chronic, open wound o her right breast with ongoing in ammation. The f rst goal
was to close the wound and ensure stable so t tissue coverage. Later, reconstructive
surgery can be per ormed on her right breast to achieve a more normal appearance,
along with contralateral surgery or symmetry. The patient lived several hundred
miles away and did not have health insurance to cover the needed breast recon-
struction. This limited her options. A variety o approaches were available to recon-
struct her right breast, including recruitment o healthy, well-vascularized tissue in
the orm o pedicle or ree aps, and autologous at trans er. However, because the
procedure needed to be per ormed entirely on an outpatient basis and the patient
had a long commute, a staged approach using local tissues was required.
RECOMMENDED SOLUTION TO THE PROBLEM
Wound packing with multiple daily dressing changes to promote healing
Appropriately timed excision o the f stulous tract and closure o the de ect
Delayed insertion o a breast implant to reconstruct the right breast
Surgery to improve the appearance o the reconstructed right breast, including
complete right nipple and areolar reconstruction
Synchronous surgery o the contralateral breast to improve symmetry
TECHNIQ UE
The patient was instructed in the technique o dressing changes. She was to do
this three times daily using Betadine solution. Later these were converted to wet-
to-dry dressings with normal saline solution. She diligently per ormed these dress-
ing changes at home. When she returned 3 months later, the open f stula was very
small. We elected to excise the wound edges and debride the base o the wound to
achieve def nitive closure. This was accomplished easily under local anesthesia in
the o f ce.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
612
The patient is shown 3 months a ter wound closure.
A breast implant was then inserted. Because the scar was adherent to underlying
structures, the wound edges were excised and the aps aggressively undermined to

Chapter 40 • Failed Expander/Implant Reconstruction

613
ree them rom the chest wall. The undersur ace o the aps was lined with thick-
ened, contracted residual scar tissue rom prior procedures. A checkerboard capsu-
lotomy was per ormed to release the scar capsule and allow ap expansion. An in-
atable expander was inserted to per orm intraoperative tissue expansion. A 550 cc
high round prof le silicone gel implant was then placed in the submammary pocket.
(Submuscular placement was not possible, because the remaining pectoral muscle
was inadequate.) The patient had an unevent ul recovery. She is shown 3 months
postoperatively. At this point in her reconstruction, she was com ortable in a vari-
ety o types o clothing and was not in a hurry (or f nancial position) to pursue ur-
ther surgery.
She waited a ull 3 years be ore having her next and f nal surgical procedure.
The f nal operation consisted o urther ref nement o the shape o her recon-
structed right breast, right nipple reconstruction, and an attempt to make her
breasts and NACs as symmetrical as possible. The ollowing maneuvers were per-
ormed: removal and replacement o the le t breast implant (to equalize breast vol-
umes), bilateral circumareolar mastopexy to symmetrize the NACs, excision o the
depressed scar o the lower inner quadrant o her le t breast, and composite gra t-
ing o the scar tissue to reconstruct the right nipple. At the same time, liposuction
was carried out to enhance def nition o the medial IMF o the right side, and au-
tologous at gra ting to correct contour irregularities o her right breast.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
614
The skin was marked preoperatively to indicate the right circumareolar mastopexy,
placement o a composite nipple gra t, areas o liposuction along the medial IMF,
and proposed areas o at gra ting to the right breast. A circumareolar pinwheel
mastopexy was per ormed using a large-caliber Prolene suture. Fat was injected
into depressed areas using the Coleman technique.

Chapter 40 • Failed Expander/Implant Reconstruction

615
Attention was then directed to the patient’s le t breast and the circumareolar mas-
topexy incisions. The capsule was opened, and the intact 700 cc silicone gel implant
was removed.
An in atable sizer was inserted, and the wound edges were temporarily approxi-
mated with skin staples. The expander was in ated with the patient in the sitting
position to determine a volume and prof le to best match the reconstructed right
breast. We chose a 500 cc moderate plus, smooth round silicone gel prosthesis. The
implant was rinsed in Betadine solution and inserted into the subglandular pocket.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
616
A periareolar purse-string suture was placed and tightened to reduce the areolar
diameter to match the opposite side. The knot was tied and deeply buried. The de-
pressed scar o the lower inner quadrant o the le t breast was elliptically excised
and ashioned into a composite gra t that was used to reconstruct the right nipple.
The patient is shown in the operating room at the completion o the procedure. She
had an unevent ul postoperative course.

Chapter 40 • Failed Expander/Implant Reconstruction

617
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 8 months a ter the f nal procedure. She has signif cant im-
provement. Although her right IMF is not as well def ned as her le t old, her
breasts, including her NACs, are relatively symmetrical. She is com ortable in
all types o apparel and is much more conf dent about her appearance when
unclothed.
TEACHING PO INTS
This case demonstrates the extent o so t tissue loss and scarring that can occur a -
ter periprosthetic in ection. This patient’s tissue damage was especially dramatic be-
cause o a series o recurrent in ections over a protracted period o time. When she
presented to us, she had severe scarring, breast de ormity, partial loss o her NAC
and a persistent f stulous tract that communicated with a residual pocket.
Several reconstructive options are available in a case such as this. One acceptable
approach is to recruit healthy, well-vascularized tissue in the orm o an adjacent
myocutaneous ap such as a latissimus dorsi or pedicle transverse rectus abdominis
myocutaneous (TRAM) ap. Alternatively, numerous ree aps are available.
Continued

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
618
A series o at gra ting procedures to replace lost volume and improve tissue qual-
ity was considered or this patient. However, she did not have insurance coverage
or reconstructive breast surgery, which limited her (f nancially) to outpatient pro-
cedures that could be per ormed in an o f ce setting or ambulatory surgical center.
She also lived several hundred miles away, which urther in uenced treatment de-
cisions. There ore we elected to per orm reconstruction with local tissues. The f rst
goal was to achieve permanent, stable skin coverage by reducing the size o the
open de ect with dressing changes, and then with excision and def nitive closure o
the f stula.
Once the wound was closed, in ammation subsided and the aps so tened. It was
then possible to reconstruct the breast by placing a tissue expander and implant
or by proceeding directly to an implant. Though volume was def cient on her right
side, skin was adequate; there ore direct implantation o a prosthesis was chosen.
This was pre erable to preliminary placement o an expander, because the patient
lived in a araway rural area where there were no acilities to per orm interval ex-
pander in ations. Thorough release o the residual scar tissue lining the old pocket,
wide undermining, and intraoperative tissue expansion helped to expand the so t
tissue envelope and achieve primary wound healing over a relatively large implant.
The patient then waited an extended period o time during which blood supply to
the damaged breast gradually improved. This long delay acilitated the f nal stage
o reconstruction, in which her breasts were made more symmetrical, her right nip-
ple and areola were reconstructed, and the contours o her right breast were en-
hanced with liposuction and at gra ting. The nipple was reconstructed with a com-
posite gra t, because the tissue in the areolar area was believed to be damaged rom
multiple procedures and a local ap would have a low probability o survival.
The patient achieved an acceptable f nal result. Other approaches would have been
success ul, perhaps with a better f nal aesthetic outcome. However, patients who
require reconstruction a ter implant-related complications o ten do not have insur-
ance coverage or complex procedures that require hospitalization, and may live a
long distance rom their treating surgeon. In such cases practical considerations and
patient pre erences play important roles in determining the most appropriate thera-
peutic strategy.
BIBLIO GRAPHY
Benelli L. A new periareolar mammaplasty: the “round block” technique. Aesthetic Plast Surg 14:93-
100, 1990.
Handel N. Managing complications o augmentation mammaplasty. In Spear SL, ed. Surgery o the
Breast: Principles and Art, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2011.
Machida BK, Liu-Shindo M, Sasaki GH, et al. Immediate versus chronic tissue expansion. Ann Plast
Surg 26:227-231; discussion 232, 1991.
Spear SL, Howard MA, Boehmler JH, et al. The in ected or exposed breast implant: management and
treatment strategies. Plast Reconstr Surg 113:1634-1644, 2004.
Spear SL, Seruya M. Management o the in ected or exposed breast prosthesis: a single surgeon’s
15-year experience with 69 patients. Plast Reconstr Surg 125:1074-1084, 2010.

40c Reconstruction With Tissue Expansion
and Contralateral Reduction Mammaplasty
n ea l h a n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 46-year-old Brazilian woman was re erred or treatment o wound-healing
problems a ter an immediate postmastectomy breast reconstruction. She was the
wi e o a clergyman temporarily assigned to a congregation in Mexico. One month
be ore presentation, the patient was diagnosed by mammography with le t breast
cancer. She underwent a modif ed radical mastectomy and immediate implant re-
construction in Mexico City. A tissue expander was not used. The patient stated
that about a week postoperatively she developed complications, the exact nature o
which was unclear. She had apparently developed either a hematoma or partial ap
necrosis that required a second operation. This was also per ormed in Mexico City.
The patient did not have her medical records. We subsequently obtained these rom
her original surgeon.
On physical examination the patient was apparently healthy, with no systemic
symptoms. She had an unusual cruciate scar on her reconstructed breast mound,
which resulted in our triangular-shaped skin aps that radiated rom a central
point. The surgical incisions were intact; however, portions o the distal aps were
ecchymotic, and some small areas o blistering were noted. There were no signs o
cellulitis, and her breast was not tender or swollen. We thought that her wounds
would heal; there ore conservative treatment was chosen. She was given oral antibi-
otics (Ke ex). Physical therapy was initiated, because she was beginning to develop
a rozen le t shoulder. Her medical records were requested rom her original sur-
geon. The patient was scheduled to return in 1 week.
In the interim we received her original medical records. She had presented approxi-
mately 5 weeks earlier with a le t breast tumor. She had a lumpectomy and sentinel
node biopsy, which was negative or metastatic disease. Four days later, a modif ed
radical mastectomy and immediate breast reconstruction with a McGhan 445 g im-
plant (Allergan Corp., Santa Barbara, CA) was per ormed. Five days a ter the mas-
tectomy and reconstruction, the patient developed necrosis o the in erior border o
the mastectomy ap. The necrotic tissue was debrided, and according to the surgi-
cal report, the surgeon used “mobilization o local skin ragments to close the cut.”
The patient’s f nal visit with her physician in Mexico was 3 weeks a ter the mastec-
tomy and approximately 2 weeks a ter wound debridement and closure. According
to the records, she was “doing well” at that time.
619

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
620
The patient returned to our o f ce a ter a 1-week course o antibiotics. She had no
signs o in ection, but the wound edges were beginning to separate at the conver-
gence o the our skin aps. A layer o so t tissue covered the implant. The patient
was a ebrile, and her breast was nontender. She continued taking oral antibiotics
and was instructed about dressing changes, which she per ormed our times daily
using Betadine solution.
At a ollow-up visit 48 hours later, her condition was deteriorating. The wound
edges had separated, leaving a de ect that measured approximately 1 by 2 cm. No
obvious signs o in ection were noted, and the implant appeared to be covered by
a thin membrane o so t tissue. However, implant exposure was imminent. The pa-
tient was given several treatment options. She was told that the most conservative
approach was explantation and a repeat attempt at reconstruction a ter the wounds
healed and the tissues so tened. She was in ormed that an attempt at salvage was
an option, but carried a signif cant risk o ailure. The patient requested salvage o
her reconstruction.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient’s reconstructed le t breast has a 1.5 cm, square-shaped, ull-thickness
so t tissue de ect o her central mound. Four linear scars radiate rom the corners
o the de ect, delineating the aps that had been advanced in an e ort to close the
wound. No overt signs o cellulitis are present.