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

Part II: Problems in Augmentation Mammaplasty
22
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient enjoyed a satis actory outcome, with restoration o excellent symmetry
o the IMFs, symmetrical nipple position, correction o lateral implant dri t, and o
the desired cleavage. The patient is shown 1 year ollowing the revision procedure.
This patient with an in ected breast implant was very motivated to save her im-
plant. Typically, breast augmentation patients are reluctant to undergo explanta-
tion, even i it is the most reliable way to eradicate in ection. It is not unreasonable
to o er patients an attempt at one-stage treatment o in ection, as long as they are
ully in ormed about the risks involved and the potential or ailure, which would
necessitate additional operations. In this instance, the salvage procedure was techni-
cally success ul, because the patient was able to retain her implant, and she was not
orced to live even temporarily without the prosthesis. On the other hand, because
o implant malposition resulting rom an aggressive capsulectomy, the patient re-
quired an additional procedure in which an ADM gra t was incorporated. Despite
the act that two operations were necessary, this patient ultimately achieved an ex-
cellent result and was satis ed with the approach she chose to ollow.

Chapter 3 • Periprosthetic Infection After Augmentation

23
TEACHING PO INTS
This case illustrates several important points relating to the management o in-
ected breast implants. With regard to the treatment o in ection, conventional
teaching has always been that when the periprosthetic space is contaminated (as in
this case), the implant should be removed, the pocket drained, and the area allowed
to heal or at least 3 to 6 months be ore proceeding with reimplantation. The ra-
tionale or this approach is to ensure ull eradication o the in ection and complete
resolution o associated inf ammatory changes. In recent years, however, there has
been increasing precedent or attempting implant salvage by surgical intervention.
The rationale is that surgical debridement o the in ected tissues, insertion o a new,
sterile prosthesis, and appropriate antibiotic coverage can resolve the in ection,
even in the presence o a relatively large oreign body. This approach is e ective in
many (but not all) cases. It is a reasonable option as long as patients are adequately
orewarned o the potential or ailure and the possible need or multiple subse-
quent procedures ( or example, explantation and delayed replacement o the pros-
thesis).
BIBLIO GRAPHY
Feldman EM, Kontoyiannis DP, Sharabi SE, et al. Breast implant in ections: is ce azolin enough? Plast
Reconstr Surg 126:779-785, 2010.
Maxwell GP, Gabriel A. Use o the acellular dermal matrix in revisionary aesthetic breast surgery.
Aesthet Surg J 29:485-493, 2009.
Spear SL, Howard MA, Boehmler JH, et al. The in ected or exposed breast implant: management and
treatment strategies. Plast Reconstr Surg113:1634-1644, 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.
Spear SL, Seruya M, Clemens MW, et al. Acellular dermal matrix or the treatment and prevention o
implant-associated breast de ormities. Plast Reconstr Surg 127:1047-1058, 2011.

3b Unilateral Explantation With Delayed Implant
Reinsertion and Mastopexy
Ja c K FISh er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This patient is 55 years old and 6 years previously had her right breast subglandu-
lar implant removed because o in ection. When she presented she had signi cant
asymmetry as a result o the implant removal. Her original augmentation was per-
ormed when she was 25, and 1 year a terward she developed capsular contrac-
ture requiring bilateral capsulectomies. Eight years later, at age 34, she required
bilateral capsulectomies or recurrent contracture. At age 45 she developed a right
ruptured saline implant and had both implants replaced with new subglandular
saline devices. At age 49 she was seen with an in ection o unknown origin o the
right breast implant, and the implant was removed. She reported that the in ection
quickly resolved a ter implant removal. The patient presented in my o ce at age 55
and had signi cant asymmetry rom the loss o the right implant. The le t implant
that had been placed 10 years previously was still in place.
24

Chapter 3 • Periprosthetic Infection After Augmentation

25
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient’s right breast has undergone secondary contracture rom repeated op-
erations as well as in ection. The diameter o the nipple-areola complex (NAC) has
been reduced and the entire areola has undergone contracture and indentation. The
patient’s le t breast, which still contains a saline implant, is more than twice the size
o the right, with signi cant ptosis. The le t areola is at least twice the size o the
right. The le t breast shows no evidence o a clinically signi cant capsule.
ANALYSIS O F THE PRO BLEM
Contracture and irregularities are common in patients who have had multiple sur-
gical procedures. This has been made worse in this woman by a history o in ection
requiring implant removal. The other sequelae associated with this patient’s history
are contracture and distortion o the right NAC. When a patient’s breasts are this
asymmetrical, there are two options or correction: put in di erent size implants,
remove breast tissue rom the larger o the two breasts and then use similar size im-
plants. In this type o patient, the latter o the two is pre erable since symmetry is
more likely to be attained by using similar size implants.
RECOMMENDED SOLUTION TO THE PROBLEM
Remove breast tissue rom the le t side to equalize volume between the two
breasts.
Per orm asymmetrical mastopexies, removing more breast tissue rom the pa-
tient’s le t breast.
Insert equal size implants in the subglandular pockets.
TECHNIQ UE
Preoperatively, the patient was marked
or bilateral mastopexies; di erent
patterns were used on the le t and
right sides. On the patient’s le t breast,
signi cantly more skin required re-
moval and more elevation o the le t
NAC compared with the right breast.
On the right side, ar less skin needed
to be removed, and minimal change
was planned or the NAC location.

Part II: Problems in Augmentation Mammaplasty
26
Next incisions were made vertically below the NAC to gain access to the origi-
nal subglandular pockets. On the le t side, the saline implant was removed, while
on the scarred right side, a new subglandular pocket was created in the previously
scarred space. Once symmetrical pockets had been created, implant sizers o equal
size were placed in the subglandular pocket, and temporary tailor-tacking based on
the mastopexy markings was per ormed. Once symmetry had been con rmed, the
tailor-tacking sutures were removed and the areas deepithelialized based on these
markings. On both sides, an inverted-T mastopexy was per ormed. On the patient’s
le t side the distance rom the bottom o the areola to the IMF was 13 cm, whereas
on the patient’s right contracted breast this distance was only 7 cm. Based on the
sizers, the permanent implants were 375 cc smooth-walled moderate pro le gels.
The inverted-T mastopexy incisions were closed in layers using 3-0 and 4-0 Vicryl
sutures or the deep layers and a running 4-0 Monocryl suture or the skin.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
There is a slight increase in volume o the le t side over the right, and in retrospect,
a little more breast tissue could have been removed rom the le t side.
The patient’s initial postoperative
photos show signi cant improvement
o the asymmetry. The NACs are now
symmetrical in location and diameter.
The le t NAC was reduced in size to
match the constricted right one.

Chapter 3 • Periprosthetic Infection After Augmentation

27
The patient at 3 years postoperatively shows recurrence o the ptosis. Fortunately,
this has occurred in a symmetrical manner as the patient has aged. She has well-
healed scars and symmetrically so t breasts.
TEACHING PO INTS
When the patient has signi cantly asymmetrical breasts, it is usually better to
remove breast tissue rom the larger breast be ore insertion o the implants when
easible. The use o symmetrical implants in cases such as this is more likely to
create long-term symmetry. Un ortunately, recurrence o ptosis in patients with im-
plants is a airly common problem, but having symmetrical ptosis is ar better than
asymmetrical ptosis.

Part II: Problems in Augmentation Mammaplasty
28
BIBLIO GRAPHY
Khan UD. Breast augmentation, antibiotic prophylaxis, and in ection: comparative analysis o 1,628
primary augmentation mammoplasties assessing the role and e cacy o antibiotics prophylaxis
duration. Aesthetic Plast Surg 34:42-47, 2010.
Khan UD. Secondary augmentation mammaplasties and periprosthetic in ection: a three-year retro-
spective review. Aesthet Surg J 32:465-473, 2012.
Laveaux C, Pauchot J, Loury J, Leroy J, Tropet Y. [Acute periprosthetic in ection a ter aesthetic breast
augmentation. Report o three cases o implant “salvage.” Proposal o a standardized protocol o
care] Ann Chir Plast Esthet 54:358-364, 2009.
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.
Thomas M, D’Silva JA, Borole AJ, et al. Periprosthetic atypical mycobacterial in ection in breast im-
plants: a new kid on the block! J Plast Reconstr Aesthet Surg 66:e16-e19, 2013.
Washer LL, Gutowski K. Breast implant in ections. In ect Dis Clin North Am 26:111-125, 2012.

3c Bilateral Explantation With Delayed Implant
Reinsertion
Lo UIS l . St r o c K
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 38-year-old woman presented or breast enhancement. She reported that her
breasts were B cup and requested augmentation to a small C cup, i possible, with
an improvement in their contour. She was healthy and had no signi cant medical
history. Her physical examination was remarkable or a moderate skin envelope
with 2.5 cm o ptosis with some degree o asymmetry o volume and shape. A -
ter thorough evaluation and discussion o treatment options, she elected to pursue
breast enhancement using a combination o augmentation with vertical mastopexy.
29

Part II: Problems in Augmentation Mammaplasty
30
Moderate plus pro le smooth-wall implants, 250 cc volume, were placed in a par-
tial subpectoral pocket using periareolar access, a ter which the vertical mastopexy
was per ormed using a tailor-tack technique. One small closed-suction drain was
used on each side, with exit sites low and lateral, away rom the surgical incisions.
Tissue was then excised within the tailor-tack markings in multilayer ashion.
Her initial postoperative course was unremarkable, except or relatively prolonged
f uid output rom the drainage tubes. The f uid was clear and decreased to less than
30 ml per day, and drains were removed 10 days postoperatively. The patient is
seen 18 days postoperatively.
At postoperative day 20, a small area
o cellulitis was noted laterally on the
right side, with a small amount o drain-
age rom the lower aspect o the vertical
mastopexy incision.

Chapter 3 • Periprosthetic Infection After Augmentation

31
She stated that she elt well and had no ever. Oral antibiotics were prescribed and
antibiotic cream was applied to the incision area. She returned 4 days later with
signi cant swelling and severe cellulitis that appeared to be concentrated in the area
adjacent to the site where the right breast drain had been placed. Treatment op-
tions were discussed, and it was agreed that the implants would be removed using
the vertical component o the mastopexy access bilaterally. She stated that she pre-
erred bilateral removal because o the asymmetry that would have resulted rom
device removal rom the right side only.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
This patient has had an unusual postoperative course a ter what had appeared to
be a very routine breast augmentation with a vertical mastopexy. Because she has
developed cellulitis that is becoming more severe despite a course o oral antibiot-
ics, it must be assumed that the tissue space surrounding the right implant is in-
volved. Implant removal is recommended. An additional challenge in this compli-
cated scenario is that the vertical mastopexy was con gured in a tailor-tack ashion
with the implant in place in such a way that removal o the implant would result
in so t tissue malposition and some distortion that would be present until the im-
plants could be replaced.
ANALYSIS O F THE PRO BLEM
Periprosthetic in ection a ter breast augmentation is a multi aceted problem that
requently requires a staged approach. In the rst stage the prosthetic device on the
involved side is removed; the implants on both sides may be removed, depending
on patient pre erence. In this instance, the patient requested that both implants be
removed. Consideration at this stage must also address the early capsule and the
degree to which it will be removed to attempt to minimize the risk o ongoing in-
ection issues. This must be weighed against preservation o tissue layers in such pa-
tients, whose tissue is usually thin.
In the second stage the devices are replaced and so t tissue re nements are done as
needed to optimize the aesthetic outcome. The timing o this second stage is not
well de ned but usually ollows the principle o at least 3 and pre erably 6 months
o complete tissue recovery with no wound issues, pain, or other signs o inf amma-
tion o the involved side.
The ocus o the rst stage is to attempt to eliminate recurrent or unresolved in ec-
tion. The ocus o the second stage is to attempt to optimize the aesthetic outcome
and to avoid asymmetry and capsular contracture. This treatment course requires
candid and repeated counseling o the patient so that she understands the overall
plan and its sequence and has appropriate expectations.

Part II: Problems in Augmentation Mammaplasty
32
RECOMMENDED SOLUTION TO THE PROBLEM
First stage
– Bilateral implant removal
– Subtotal or total capsulectomy (approach chosen a ter intraoperative evalua-
tion) on the involved side
Second stage
– Implant replacement
– So t tissue re nement as needed at time o device replacement
TECHNIQ UE
FIRST STAGE
Because in ection was present in the right breast and the patient requested that
both devices be removed, the rst-stage procedure was started on the uninvolved
le t breast to attempt to spare this site rom the risk o in ection. The vertical inci-
sion line o the le t mastopexy was opened and the device was removed. There were
no remarkable ndings. The pocket was rinsed with povidone-iodine (Betadine) so-
lution (patient consent or this o -label use o the antiseptic solution was obtained
preoperatively), a small drain was placed, and a multilayer closure was per ormed.
This closure was then covered with a large OpSite dressing and covered in prepara-
tion or the procedure on the involved side.
On the right breast, the vertical incision line was excised and entered. Tissue layers
were cut until the implant was encountered and removed. Slightly murky, yellow-
straw-colored f uid was drawn and sent or aerobic, anaerobic, and mycobacterial
culture. A subtotal capsulectomy was per ormed. The tissue pocket was irrigated
with Betadine solution and then a saline rinse, and then reirrigated with Betadine.
The debrided tissue pocket was then recultured. A drain was placed and a multi-
layer closure was completed. No attempt was made to otherwise adjust the mas-
topexy, the strategy being to acilitate eventual completion in the second stage.
The patient was counseled to expect some degree o de ormity or distortion o the
involved side until the second-stage implant replacement was per ormed. She is
shown at 11 days a ter bilateral implant removal.

Chapter 3 • Periprosthetic Infection After Augmentation

33
The patient’s postoperative course rom the rst stage was unremarkable. The in-
traoperative cultures, be ore debridement, were positive or methicillin-resistant
Staphylococcus aureus (MRSA). The postdebridement culture showed no growth.
Assistance was requested rom an in ectious disease consultant to assist with anti-
biotic management, which included 3 weeks o intravenous antibiotics, ollowed by
3 weeks o oral antibiotics.
SECO ND STAGE
A ter ongoing discussions and counseling with the patient, the second-stage proce-
dure was pursued 7 months a ter implant removal. Antibiotic management or the
second stage was directed by the in ectious disease consultant. The patient is shown
be ore her second-stage procedure.
The second-stage procedure began with the uninvolved le t breast. The vertical
mastopexy incision was excised and entered, and the partial subpectoral pocket
was reopened. Once re-created, the pocket was irrigated with antibiotic solution
in preparation or device placement. A 250 cc smooth wall moderate plus pro le
silicone gel implant was brought into the operative eld, placed in antibiotic solu-
tion, and then placed into the partial subpectoral space with the aid o an insertion
sleeve.

Part II: Problems in Augmentation Mammaplasty
34
The patient was placed in a sitting position to con rm the level and shape o the
IMF and then returned to the supine position. A small closed-suction drain was
placed using a separate stab incision laterally. The deep tissue layer was closed over
the implant and the vertical limb was tacked in place. Excellent shape was noted.
Attention was shi ted to the contralateral side, where an identical procedure was
per ormed. The vertical mastopexy was then revised using a tailor-tack technique,
a ter which de nitive closures were done in a multilayer ashion. When the proce-
dure was completed, a pressure dressing was placed. The patient was maintained on
a leukotriene inhibitor (montelukast; o -label consent was obtained) or 6 months
postoperatively. The patient is shown 11 days postoperatively a ter bilateral im-
plant replacement and revision vertical mastopexy.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The postoperative photographs at 9 months show a stable result, with adequate
symmetry and correction o her ptosis.

Chapter 3 • Periprosthetic Infection After Augmentation

35
There has been no evidence o recurrent in ection or capsular contracture. There is
a slight degree o asymmetry o her breast tissue, but the shape o her breasts is ex-
cellent overall. She has maintained a so t result with no evidence o recurrent cap-
sular contracture.
TEACHING PO INTS
Periprosthetic in ection a ter breast augmentation is unusual and a challenge or
both the patient and surgeon. Multiple stages are needed, all o which are aimed
at minimizing the risk o ongoing in ection. The rst stage ocuses on removal o
the device and aggressive debridement o the implant capsule as indicated. The ini-
tial culture provides guidance or antibiotic selection and management. The post-
debridement culture is critical to con rm adequate surgical treatment o the tissue
pocket in the rst stage. Consultation by an in ectious disease specialist is encour-
aged to ensure that antibiotic management is optimal. An interval is needed to al-
low the inf ammation to subside be ore device replacement. This is a critical step to
end the problem and prevent recurrent in ection. The second surgical stage ocuses
on re-creation o the implant pocket and, in this case, re nement o the so t tissue
position with a revision mastopexy.
BIBLIO GRAPHY
Feldman EM, Kontoyiannis DP, Sharabi SE, et al. Breast implant in ections: is ce azolin enough? Plast
Reconstr Surg 126:779-785, 2011.
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.

3d Salvage of an Infected Augmentation With a Tissue
Expander and Secondary Implants
Br Ia n d . Pet er So n
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 26-year-old nulliparous woman was initially seen or a primary augmentation.
She had no previous history, either personal or amilial, related to her breasts. She
was a healthy nonsmoker who was not receiving any prescription medication and
had no history o allergies. She weighed 125 pounds and was 5 eet 4 inches tall.
The patient underwent a subpectoral breast augmentation with an unevent ul ini-
tial recovery.
36

Chapter 3 • Periprosthetic Infection After Augmentation

37
However, 7 weeks postoperatively she presented with a tender, swollen erythema-
tous le t breast. Initial attempts with antibiotic treatment were unsuccess ul. She de-
veloped systemic symptoms, and 5 days a ter antibiotics began, the le t implant was
removed and a drain inserted. She continued on antibiotic therapy. Over the next
3 months her le t breast developed a contracted lower pole with an elevated IMF.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The initial preoperative evaluation reveals a thin patient with airly symmetrical
breasts that are a small A cup. She has high in ramammary olds with a short
areola-to-IMF distance. At the time o the original surgery, the IMFs o both breasts
were lowered 2 cm and the breast tissue released internally to allow expansion o
the lower pole. Smooth wall high pro le implants o 425 cc were inserted through
the adjusted IMF incisions. The upper poles o the implants were placed subpecto-
rally and the lower poles subglandularly (dual plane).

Part II: Problems in Augmentation Mammaplasty
38
She was seen at 7 weeks with an in ected le t implant, which was removed because
o the lack o response to antibiotics. The patient’s breast was allowed to heal or
the next 3 months. Then the patient presented or secondary augmentation. At this
time, the lower pole o the breast is contracted and the le t IMF elevated.
ANALYSIS O F THE PRO BLEM
In ection a ter primary breast augmentation is rare. In this patient, no postopera-
tive events could be identi ed to explain why she had developed a postoperative
in ection. Analysis o her preoperative photos and those at 3 months a ter implant
removal highlighted several key points. The loss o her lowered old and signi cant
contracture o the lower breast pole was to be expected. Once the orce o an im-
plant is removed, the breast tends to return to its original con guration. Then the
secondary in ection added to the process o contracture, with inf ammation and
scar ormation. The question at 3 months a ter implant removal was whether an
implant could be placed or whether another process, such as expansion, was neces-
sary to regain the appropriate breast contour and shape.

Chapter 3 • Periprosthetic Infection After Augmentation

39
RECOMMENDED SOLUTION TO THE PROBLEM
Because o the extent o scarring, the loss o the IMF, and the degree o so t tissue
contracture, the ollowing was determined:
Expansion was considered the best option to create de nition and long-term
stability
Insertion o a new implant directly would be di cult at this time
Selection o a textured device to enhance tissue adherence would aid creation
o a new IMF
TECHNIQ UE
A textured tissue expander was placed in the original augmentation pocket, subpec-
toral superiorly and subglandular in eriorly. At the time o expander insertion, the
scar was released in the lower pole and dissection was carried in eriorly to reestab-
lish the IMF level created at the rst procedure. Over a 3-month period, expansion
was carried out until a volume o 450 cc was obtained. At the appropriate time, the
expander was removed and replaced with a 425 cc implant.

Part II: Problems in Augmentation Mammaplasty
40
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
One year a ter insertion o the new le t implant,
the patient has good shape and symmetry. She
has a grade I capsule. The lower pole o the le t
breast expanded well, and the IMF created at
the original operation and reestablished by the
textured expander has remained stable.

Chapter 3 • Periprosthetic Infection After Augmentation

41
TEACHING PO INTS
Although postoperative periprosthetic in ection is a rare event, it is di cult to deal
with, since these patients usually ail conservative management with antibiotic ther-
apy and require implant removal and secondary reconstruction. Secondary implant
placement alone is o ten not possible because o the so t tissue contraction associ-
ated with the resolution o the in ection. Tissue expanders are an essential part o
this reconstructive procedure and allow reasonable healing periods between inter-
ventions. This also orestalls the patient’s desire or an immediate “ x.”
The act that this patient originally had a high tight old was a key actor in this
case. I this patient had had a normal old with adequate lower pole breast tissue,
an expander may have not been necessary. When an in ection occurs in a primary
breast augmentation and the implant must be removed, the secondary procedures
required are o ten determined by the original con guration o the breast. High tight
olds with early implant removal or whatever reason tend to return to their origi-
nal shape.
BIBLIO GRAPHY
Bennett SP, Fitoussi AD, Berry MG, Couturaud B, Salmon RJ. Management o exposed, in ected
implant-based breast reconstruction and strategies or salvage. J Plast Reconstr Aesthet Surg
64:1270-1277, 2011.
De Lorenzi C. Success ul treatment o acute periprosthetic breast in ection with curettage, pulse la-
vage, and immediate device exchange. Aesthet Plast Surg 29:400-403, 2005.
Feldman EM, Kontoyiannis DP, Sharabi SE, et al. Breast implant in ections: is ce azolin enough? Plast
Reconstr Surg 126:779-785, 2010.
Fodor L, Ramon Y, Ullmann Y, et al. Fate o exposed breast implants in augmentation mammoplasty.
Ann Plast Surg 50:447-449, 2003.
Gatti GL, Lazzeri D, Stabile M, et al. Salvage o an in ected and exposed breast device with implant
retention and delayed exchange. Plast Reconstr Surg 125:19e-20e, 2010.
Hammond DC. Discussion: Management o the in ected or exposed breast prosthesis: a single sur-
geon’s 15-year experience with 69 patients. Plast Reconstr Surg 125:1085-1086, 2010.
Kendrick AS, Chase CW. Salvage o an in ected breast tissue expander with an implant sizer and nega-
tive pressure wound management. Plast Reconstr Surg 121:138e-139e, 2008.
Munhoz AM, Gemperli R. Management o the in ected or exposed breast prosthesis: a single sur-
geon’s 15-year experience with 69 patients. Plast Reconstr Surg 126:2289-2290, 2010.
Prince MD, Suber JS, Aya-Ay ML, et al. Prosthesis salvage in breast reconstruction patients with peri-
prosthetic in ection and exposure. Plast Reconstr Surg 129:42-48, 2012.
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.

(Trang không có chữ)

4a Implant Removal and Replacement
El iz a bet h J. Ha l l -Fin d l ay
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
When this 46-year-old patient was initially seen, she reported intermittent but pro-
gressive swelling in her le t breast o two months’ duration. Fi teen years earlier she
had had breast augmentation in subpectoral pockets. She had no history o in ec-
tion, recent teeth cleaning, or other relevant actors. Otherwise she elt well. There
was no history o trauma. She was 5 eet 6 inches tall and weighed 140 pounds.
43
c H a Pt Er 4
LATE SEROMA AFTER
AUGMENTATION

Part II: Problems in Augmentation Mammaplasty
44
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
An ultrasound showed uid surrounding her le t implant. She was taken to the op-
erating room, and a large amount o serosanguineous uid removed. There were no
signs o in ection. The implants were CUI MicroCell implants with an aggressive
textured sur ace. The implants were intact, but the le t implant was stained yellow
rom contact with blood. The implants were in a subpectoral location, and there
were riable granulations on the ribs. These granulations bled easily when touched
and were cauterized.
The capsule was thick with multiple olds and a rough sur ace consistent with con-
tact with a textured implant.
ANALYSIS O F THE PRO BLEM
The aggressive textured sur ace was developed on implants to help replicate the
benef cial e ects o the polyurethane implants. The polyurethane textured sur ace
allowed tissue ingrowth and appeared to help reduce the risk o capsular contrac-
ture. Un ortunately, true tissue ingrowth does not occur with the texturing cre-
ated on the silicone envelope itsel . Adherence only occurs with the more aggres-
sively textured envelopes. This adherence can be patchy, and it can be undone (like
Velcro) with trauma; or example, this occurred in one patient when her toddler
stepped on her breast in bed; another patient had a rough sexual partner; and a
third woman’s implant adherence was damaged during a mammogram.
The kidney basin is shown f lled with
some o the serosanguineous uid
rom the le t breast. Both implants
were intact; the le t one can be seen
to be stained by contact with blood.

Chapter 4 • Late Seroma After Augmentation

45
The granulations on the ribs were clearly being irritated and causing bleeding as
a result o movement o the rough sur ace o the implant over them. Sometimes
these implants are adherent, but usually only in the upper pole. Textured tissue ex-
panders are more likely to be completely adherent because o the pressure exerted
against the capsule when the device is f lled.
RECOMMENDED SOLUTION TO THE PROBLEM
Implant removal and replacement with smooth-walled cohesive silicone gel im-
plants
Cauterization o granulations
Removal o abnormal capsule or anaplastic large cell lymphoma (ALCL) testing
TECHNIQ UE
The patient requested larger implants. The original implants were 320 cc each,
and these were replaced with smooth-walled Inspira implants that were 470 g
each. The patient had no recurrence o swelling, but un ortunately, she developed
a double-bubble de ormity on the le t side.

Part II: Problems in Augmentation Mammaplasty
46
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown initially with the recurrent seroma o the le t breast. The
implants were replaced with larger smooth implants back into the subpectoral
pockets, but she developed a double-bubble de ormity. She then underwent an in-
erior capsulorrhaphy o the le t breast to correct the double-bubble problem that
occurred rom bottoming out. Larger implants, as used in this case in a subpectoral
pocket, can result in in erior malposition and cause a double-bubble de ormity.
Replacement o the textured-sur ace implants with smooth implants produced a
satis actory result. I have seen numerous patients with late seromas associated with
aggressively textured implants, and I think these late seromas are caused by riction.
Repair o the double-bubble provided an
opportunity to reinspect the areas o gran-
ulation. They were still clearly visible but
were now covered with smooth capsule.

Chapter 4 • Late Seroma After Augmentation

47
The evidence in this case with the granulation tissue on the ribs that bled when
touched conf rmed my opinion that riction is o ten the cause o late seromas.
Cauterization alone might have solved the problem, but being able to see the new
smooth capsule over them when revising the double-bubble (results shown in lower
two photos) helped rein orce my thinking that late seromas are o ten a problem o
riction. It made sense to have replaced the textured implant with a smooth one to
help solve the problem long term.
TEACHING PO INTS
Seromas develop when two sur aces rub against each other. Seromas develop in
mastectomy sites, latissimus donor sites, and a ter abdominoplasty. The incidence
o seromas can be dramatically reduced with the use o quilting sutures to stop the
shear orces o one sur ace rubbing against another. I think that aggressively tex-
tured implants can cause the development o seromas i they are not completely
adherent to the capsule or when they are orcibly separated rom the capsule, com-
pletely or partially. Sometimes seromas will wax and wane (leading, I believe, to the
development o double capsules). Swelling in one breast is o ten thought to be an
in ection, but i the seroma settles when antibiotics are given, this does not neces-
sarily imply cause and e ect.

Part II: Problems in Augmentation Mammaplasty
48
BIBLIO GRAPHY
Brickman M, Parsa NN, Parsa FD. Late hematoma a ter breast implantation. Aesthetic Plast Surg
28:80-82, 2004.
Daw JL, Lewis VL, Smith JW. Chronic expanding hematoma within a periprosthetic breast capsule.
Plast Reconstr Surg 97:1469-1472, 1996.
Gonzalez R. Late intracapsular seroma in sub ascial buttock augmentation: a case report. Aesthetic
Plast Surg 30:599-604, 2006.
Goyal A, Mansel RE. Haematoma as a late complication a ter breast reconstruction with implant. Br J
Plast Surg 56:189-191, 2003.
Hall-Findlay EJ. Breast implant complication review: double capsules and late seromas. Plast Reconstr
Surg 127:56-66, 2011.
Hsiao HT, Tung KY, Lin CS. Late hematoma a ter aesthetic breast augmentation with saline-f lled,
textured silicone prosthesis. Aesthetic Plast Surg 26:368-371, 2002.
Marques AF, Brenda E, Saldiva PH, et al. Capsular hematoma as a late complication in breast recon-
struction with silicone gel prostheses. Plast Reconstr Surg 89:543-545, 1992.
Mauro S, Eugenio F, Roberto B, et al. Late recurrent capsular hematoma a ter augmentation mamma-
plasty: case report. Aesthetic Plast Surg 29:10-12, 2005.
Mazzocchi M, Dessy LA, Carlesimo B, et al. Late seroma ormation a ter breast surgery with textured
silicone implants: a problem worth bearing in mind [letter to the editor]. Plast Reconstr Surg
125:176e-177e, 2010.
Pinchuk V, Tymof i O. Seroma as a late complication a ter breast augmentation. Aesthetic Plast Surg
35:303-314, 2011.
Pineda V, Cáceres J, Pernas JC, et al. Retromammary uid collection as a late complication o breast
implants: magnetic. Magnetic resonance imaging f ndings. J Comput Assist Tomogr 28:386-389,
2004.
Roman S, Perkins D. Progressive spontaneous unilateral enlargement o the breast twenty-two years
a ter prosthetic breast augmentation. Br J Plast Surg 58:88-91, 2005.
Tebbetts JB. Diagnosis and management o seroma ollowing breast augmentation: an update. Plast
Reconstr Surg 128:17-25, 2011.
Veiga DF, Filho JV, Schnaider CS, et al. Late hematoma a ter aesthetic breast augmentation with tex-
tured silicone prosthesis: a case report. Aesthetic Plast Surg 29:431-433, 2005.
Wang BH, Chang BW, Sargeant R, et al. Late capsular hematoma a ter breast reconstruction with
polyurethane-covered implants. Plast Reconstr Surg 102:450-452, 1998.

4b Surgical Drainage With Implant Exchange
Fr a n k List a , Ja mil a h ma d
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 37-year-old woman underwent subglandular breast augmentation through an
in ramammary incision with textured, anatomically shaped, cohesive silicone im-
plants (Allergan Style 410 MF 420 g). She did well postoperatively and was happy
with the result. Four years later, she presented a ter experiencing sudden-onset
swelling and discom ort o the right breast. She denied any history o recent trauma
and was a ebrile. This woman was a healthy nonsmoker with no signif cant medical
issues.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
This patient’s right breast is signif cantly larger than the le t. In addition to the vol-
ume asymmetry because o right breast swelling, she also has inherent breast asym-
metry with the in erior pole o the right breast appearing shorter than that o the
le t breast. She has NACs that are lateral to the central axes o the breasts. There is
no redness or induration and no signs o acute in ection. The breast is so t and the
implant is palpable but does not have capsular contracture. There are no masses
palpable in either breast and there is no lymphadenopathy.
ANALYSIS O F THE PRO BLEM
Late periprosthetic uid collection re ers to any uid collection around a breast
implant occurring 1 year or more a ter surgery. Late seroma is a distinct entity
rom early postoperative seroma, which occurs immediately a ter surgery; late se-
roma has been arbitrarily def ned to occur at least 1 year a ter surgery. The exact
developmental mechanism and risk actors or late periprosthetic uid collection
are unknown. Several possible etiologies have been proposed including vascular or
lymphatic leakage that occurs in comorbid conditions such as in ammation rom
a bacterial in ection, hematoma, or other trauma, or idiopathic reasons related to
breast augmentation or reconstructive surgery, cancer, or lymphoproli erative dis-
49

Part II: Problems in Augmentation Mammaplasty
50
orders. Late periprosthetic uid collections have been associated with the presence
o a double capsule but the exact relationship is unknown. It appears that textured
implants are more commonly associated with the development o both double cap-
sule and late periprosthetic uid collections compared with smooth implants. Al-
though there has been speculation that the Allergan Biocell texturization process
may play a signif cant role in the development o both double capsule and late peri-
prosthetic uid collection, double capsule has been observed with Mentor Siltex
textured shell implants.
With acute breast swelling, it is essential to rule out in ection. I a late peripros-
thetic uid collection is suspected, there are several options or evaluation and
treatment ranging rom the use o nonsteroidal antiin ammatory drugs (NSAIDs)
and expectant management to needle aspiration to surgery. I the periprosthetic
uid collection is drained, it should be sent or cultures to rule out in ection and
cytology to rule out malignancy. Where surgery is required, options include sur-
gical drainage with cultures and cytology, capsule biopsy, capsulectomy, implant
removal, and/or implant exchange. Our current strategy or managing late peri-
prosthetic uid collections involves removal o the textured device, specimens o
periprosthetic uid or cultures and cytology along with capsule biopsy, ollowed
by immediate replacement with smooth, round silicone gel implants. We have used
this strategy in several patients with resolution o symptoms and no recurrence at
long-term ollow-up.
RECOMMENDED SOLUTION TO THE PROBLEM
Incision and drainage o right breast late seroma with cultures, cytology, capsule
biopsy, and possible capsulectomy
Exchange o bilateral breast implants to smooth, round, silicone gel implants
TECHNIQ UE
The previous in ramammary scars were marked preoperatively. No prophylactic
antibiotics should be given until cultures o the uid have been obtained. An inci-
sion was made through the in ramammary scar and was continued down to the
capsule. The capsule was incised allowing straw-colored uid consistent with a late
seroma to drain.
Cultures o this uid were taken or
aerobic, anaerobic, ungal, and mycobac-
terial cultures. Fluid was also aspirated
and sent or cytology.

Chapter 4 • Late Seroma After Augmentation

51
It is important to speci y on the pathologic requisition that the uid should be ex-
amined to rule out anaplastic large cell lymphoma so that the appropriate tests are
per ormed. A small 1 3 1 cm patch o capsule adjacent to the incision was biop-
sied and sent to pathology as well. Examination o the right breast implant revealed
minimal adherence to the surrounding breast tissue. Instead, there was a double
capsule with a well- ormed capsule around the implant and lining the breast tissue.
The right breast implant was removed. Removal o the le t breast implant was per-
ormed in the same manner. Although no periprosthetic uid collection was ound,
there was a double capsule on this side as well.
Examination o both breast pockets revealed well- ormed capsules that were so t
and smooth. There were no suspicious-appearing areas o capsule so capsulectomy
was not per ormed.
The pockets were irrigated with triple antibiotic solution and then smooth, round
silicone gel implants (Allergan Inspira SRM 400 g) were inserted bilaterally. The in-
ramammary incision was closed in layers.

Part II: Problems in Augmentation Mammaplasty
52
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 4 months a ter incision and drainage o the right breast late
seroma with cultures, cytology, and capsule biopsy along with exchange o bilateral
breast implants to smooth, round, silicone gel implants. Cultures, cytology, and pa-
thology did not yield any abnormal results. The appearance o her breasts is similar
to the appearance be ore the development o the late periprosthetic uid collection.
Notice the appearance o the le t breast with a textured, anatomically shaped im-
plant preoperatively and a smooth, round implant postoperatively. It is very di f -
cult to distinguish between the two implants in this patient.

Chapter 4 • Late Seroma After Augmentation

53
TEACHING PO INTS
I no capsulectomy has been per ormed, the use o a textured device may not allow
or adherence o the existing capsule to the textured sur ace, leading to malrota-
tion o an anatomically shaped implant or micromechanical sheer and possible re-
currence o the late periprosthetic uid collection. Thus we pre er to use a smooth,
round implant o approximately the same volume. Care ul consideration o the
surgical plan is essential. Capsulectomy is not required in all cases and can lead
to increased risk o problems including loss o control o the pocket, thinning o
implant coverage, and increased risk o hematoma. Capsulectomy should be per-
ormed i the capsule appears grossly abnormal (that is, thickened, calcif ed, any
suspicious-appearing masses or irregularities) or i use o a textured implant is
required. In this particular situation, a relatively simple surgical approach was used
to achieve an acceptable result while avoiding unnecessary risks.
BIBLIO GRAPHY
Bengtson B, Brody GS, Brown MH, et al. Managing late periprosthetic uid collections (seroma) in
patients with breast implants: a consensus panel recommendation and review o the literature.
Plast Reconstr Surg 128:1-7, 2011.
Hall-Findlay EJ. Breast implant complication review: double capsules and late seromas. Plast Reconstr
Surg 127:56-66, 2011.
Lista F, Ahmad J. Evidence-based medicine: augmentation mammaplasty. Plast Reconstr Surg 132:1684-
1696, 2013.
Lista F, Tutino R, Khan A, et al. Subglandular breast augmentation with textured, anatomic, cohesive
silicone implants: a review o 440 consecutive patients. Plast Reconstr Surg 123:295-303, 2013.
Spear SL, Rottman SJ, Glicksman C, et al. Late seromas a ter breast implants: theory and practice.
Plast Reconstr Surg 130:423-435, 2012.

(Trang không có chữ)

C h a p t e r 5
CAPSULAR CONTRACTURE
AFTER AUGMENTATION
5a Periareolar Capsulectomy With Implant Replacement
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
At the time this woman was seen, she was 38 years o age. At age 24, she had had
a transaxillary augmentation with saline implants. Her primary complaints were
breast rmness and what she considered to be an abnormal shape. Over time the
breasts had become spherical as a result o contracture, with f attening o the supe-
55

Part II: Problems in Augmentation Mammaplasty
56
rior poles at the junction between the implants and the pectoralis muscle. The pa-
tient also requested a moderate increase in size. She knew that her original saline
implants had been lled to 250 cc.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has Baker III capsules with a spherical shape to the breasts as a result
o encapsulation. Because the implants are subglandular, there is a sharp dropo
between the superior poles o the implants and the underlying pectoralis muscle.
Additionally, because o the capsular contracture, over time there has been a pro-
gressive increase in the separation o the breasts medially.
ANALYSIS O F THE PRO BLEM
The patient’s original augmentation was done through a transaxillary incision. The
implants are sitting in a relatively high position. At this time it is not possible to
determine whether this is a result o inadequate dissection originally or elevation o
the old rom the contracture. It is very di cult to make these corrections through
a transaxillary incision; it is usually best to revise either through an in ramammary
or a periareolar approach. Another major decision or this particular patient is
whether to put the implants back in the original subglandular pocket or to convert
to a submuscular pocket. An argument can be made that the chances o the pa-
tient’s developing a second capsule might be slightly lower by placing the implants
submuscularly; however, because this patient has several centimeters o breast tis-
sue, we elected to per orm capsulectomies and to put the implants back in the origi-
nal subglandular pockets.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the original saline implants through a periareolar incision
Total capsulectomies
Enlargement o the original subglandular pockets with lowering o the IMF
Replacement o the original 250 cc saline implants with 300 cc moderate pro le
smooth-walled gel implants

Chapter 5 • Capsular Contracture After Augmentation

57
TECHNIQ UE
An in erior periareolar incision was made and carried down through the breast tis-
sue to the level o the capsule. The capsule was incised and the intact saline implant
removed. Using a lighted retractor and cautery, we per ormed total capsulectomies
in a symmetrical manner on both sides. Once the capsules had been removed, the
IMF was lowered symmetrically on both sides. We per ormed conservative dissec-
tion medially and laterally to create a pocket that would accommodate a wider
base implant than the originals. Once hemostasis had been obtained, the pockets
were irrigated with antibiotic solution and the 300 cc smooth-walled gel implants
were inserted. The periareolar incisions were closed in layers, and the patient was
placed into a surgical bra.
Contracted
capsule
Secondary
periareolar
incision site
Contracted
capsule
Dissection
to lower
the IMF
Capsule
removed
Original
transaxillary incision
Extent of new
pocket dissection
Secondary
periareolar incision
Location
of new IMF
Original
implant location

Part II: Problems in Augmentation Mammaplasty
58
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient was seen or ollow-up 11⁄2 years a ter surgery; her breasts have main-
tained excellent shape and contour. Lowering o the old has placed the NAC in a
more natural location on the breast mound. Also, using a wider base implant has
created improved cleavage and a better superior slope to the breast. The breasts
have remained so t without recurrence o the original capsules.

Chapter 5 • Capsular Contracture After Augmentation

59
TEACHING PO INTS
It is di cult to correct secondary problems through the original transaxillary inci-
sion; there ore most surgeons would use either a periareolar or in ramammary ap-
proach. Using the proper base diameter implant is a undamental rule in not only
primary but also in secondary cases. O ten what appears to be malposition o the
NAC or a less-than-ideal location is really a result o improper pocket creation.
BIBLIO GRAPHY
Blount AL, Martin MD, Lineberry KD, et al. Capsular contracture rate in a low-risk population a ter
primary augmentation mammaplasty. Aesthet Surg J 33:516-521, 2013.
Dickinson BP, Handel N. Approaching revisional surgery in augmentation and mastopexy/augmenta-
tion patients. Ann Plast Surg 68:12-16, 2012.
Giordano S, Peltoniemi H, Lilius P, Salmi A. Povidone-iodine combined with antibiotic topical irriga-
tion to reduce capsular contracture in cosmetic breast augmentation: a comparative study. Aes-
thet Surg J 33:675-680, 2013.
Hester TR Jr, Ghazi BH, Moyer HR, Nahai FR, Wilton M, Stokes L. Use o dermal matrix to prevent
capsular contracture in aesthetic breast surgery. Plast Reconstr Surg 130(5 Suppl 2):126S-136S,
2012.
Khan UD. Breast augmentation, antibiotic prophylaxis, and in ection: comparative analysis o 1,628
primary augmentation mammoplasties assessing the role and e cacy o antibiotics prophylaxis
duration. Aesthetic Plast Surg 34:42-47, 2010.
Lee HK, Jin US, Lee YH. Subpectoral and precapsular implant repositioning technique: correction o
capsular contracture and implant malposition. Aesthetic Plast Surg 35:1126-1132, 2011.
Mazzocchi M, Dessy LA, Al ano C, et al. E ects o za rlukast on capsular contracture: long-term re-
sults. Int J Immunopathol Pharmacol 25:935-944, 2012.
Moyer HR, Ghazi BH, Losken A. The e ect o silicone gel bleed on capsular contracture: a genera-
tional study. Plast Reconstr Surg 130:793-800, 2012.
Tamboto H, Vickery K, Deva AK. Subclinical (bio lm) in ection causes capsular contracture in a por-
cine model ollowing augmentation mammaplasty. Plast Reconstr Surg 126:835-842, 2010.
Xue H, Lee SY. Correction o capsular contracture by insertion o a breast prosthesis anterior to the
original capsule and preservation o the contracted capsule: technique and outcomes. Aesthetic
Plast Surg 35:1056-1060, 2011.

5b Saline Implant Removal, Total Capsulectomy,
and Replacement With Gel Implants
n ea l h a n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 50 year-old woman was re erred to us by her plastic surgeon or intractable
capsular contracture. The patient had her initial breast augmentation 24 years ear-
lier. Her implants were placed in the submammary position. The patient recalled
that her rst surgery was complicated by a hematoma requiring surgical drainage;
she could not remember which side. She subsequently developed symptomatic con-
tracture and underwent removal and replacement o her implants, with conversion
to the submuscular position. Over time, the patient developed “snoopy dog” de or-
mity o both breasts (likely caused by recurrent contracture) that required yet an-
other operation. The patient reported that the outcome o that revision was satis-
actory. Un ortunately she developed recurrent capsular contracture and underwent
yet another revision 7 years prior to presenting with us. The patient stated that her
surgeon did “not do anything” speci cally to the capsule (that is, capsulotomy or
capsulectomy), but rather replaced her silicone gel implants with smaller volume
60

Chapter 5 • Capsular Contracture After Augmentation

61
(325 cc) saline- lled prostheses. Over the past several years, she noted the bilateral
onset o gradually worsening contracture. On examination we ound that she had
rm, spherically de ormed, high-riding breasts. She complained that it was uncom-
ortable to lie prone, and she was embarrassed about the appearance o her breasts.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient is a slender but healthy-appearing middle-aged woman (5 eet 5 inches,
110 pounds). She has postbilateral augmentation mammaplasty through well-
healed, slightly retracted periareolar scars. The breasts are spherically de ormed,
very rm to palpation, and moderately tender bilaterally (Baker grade IV contrac-
tures). There is excessive upper pole ullness and abnormally wide cleavage. When
the patient f exes her pectoral muscles, the implants appear to be submuscular.
ANALYSIS O F THE PRO BLEM
This patient is one o a relatively small percentage o breast augmentation patients
who have repeated episodes o capsular contracture despite appropriate surgical in-
terventions. It is likely that her initial episode o contracture was related to a post-
operative hematoma. She has subsequently undergone repeated revisions and devel-
oped recurrent contracture, both with silicone implants and saline implants as well
as with subpectoral and submammary placement. Patients with a history o re rac-
tory capsular contracture are always at increased risk or recurrence, regardless o
which measures are undertaken. The only “guaranteed” way to prevent contracture
in these individuals is to permanently explant the prostheses. However, or most o
these patients, including this woman, that is not a viable alternative.
The most recent hypotheses regarding the cause o contracture postulate that sub-
clinical in ections, speci cally in the orm o bacterial bio lms, play an important
role in precipitating contracture. Preventing recurrent contracture there ore relies
on employing a variety o strategies that reduce the risk o bacterial contamina-
tion o both the prosthesis and the pocket. Among the speci c practices that have
been shown (at least in some studies) to reduce the risk o recurrent contracture are
reduction o potential contamination by use o nipple shields, insertion o a new
sterile breast implant, antibiotic or povidone-iodine (Betadine) pocket irrigation,
meticulous hemostasis, more aggressive capsulectomy, placement o implants into
a “virgin” space, submuscular positioning o implants, the use o textured sur ace
devices, and possibly the administration o postoperative antiinf ammatory agents
(speci cally leukotriene inhibitors). In this case, the patient was o ered revision
employing as many o these modalities as possible, in the hope that her ultimate
risk o recurrence would be reduced. O course, actors other than trying to reduce
the risk o recurrent contracture also should be taken into account in planning the
correct approach. For example, the pliability and thickness o the so t tissue enve-
lope are important in determining the extent o capsulectomy, the ideal plane or
implant insertion, and the proper size and style prosthesis.

Part II: Problems in Augmentation Mammaplasty
62
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the subpectoral saline implants through the existing scar
Total capsulectomy
Antibiotic irrigation o pocket
Packing o pockets with lap sponges soaked in Betadine
Insertion o new textured (Siltex) gel- lled implants
Placement o suction drains
Postoperative leukotriene antagonist regimen with montelukast (Singulair)
TECHNIQ UE
With the patient supine on the operating table, the midline o the sternum is
marked along with the medial borders o the desired nal pocket. The old periareo-
lar scar is incised and the anterior sur ace o the subpectoral capsule is exposed. A
capsulotomy incision was made and the saline- lled implant removed. The edges o
the scar tissue capsule are then securely grasped and, under traction, the capsule is
dissected away rom adjacent structures.

Chapter 5 • Capsular Contracture After Augmentation

63
Cautery dissection is used to remove the capsule rom the chest wall posteriorly
and rom the overlying breast parenchyma and undersur ace o the pectoralis ma-
jor muscle anteriorly. In this ashion the entire scar tissue capsule is removed. The
pocket is irrigated with double antibiotic solution (bacitracin and neomycin) and
then packed with lap sponges soaked in Betadine solution. Identical steps are car-
ried out on the contralateral (right) side, where again the entire scar tissue capsule
surrounding the implant is extirpated. A sizer is inserted to ensure that the implant
selected or insertion will com ortably t the pocket; any contour irregularities are
corrected by additional cautery dissection. A 7 mm f at Jackson-Pratt suction drain
is placed in the subpectoral pocket.

Part II: Problems in Augmentation Mammaplasty
64
Once complete hemostasis has been secured bilaterally, 375 cc Siltex silicone gel-
lled implants are inserted; the implants are immersed in Betadine solution both to
reduce potential bacterial contamination and to acilitate insertion o the textured
implants into the pocket. The operative incisions are closed in layers. On postoper-
ative day 1, the patient is started on a prophylactic leukotriene antagonist regimen
consisting o Singulair 10 mg orally at bedtime daily or 3 months.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient had an unremarkable postoperative recovery and achieved a satis ac-
tory result and natural breast shape at 9 months postoperative. Her capsular con-
tracture has been alleviated. Spherical breast de ormity, upper pole convexity, and
excessively wide cleavage have all been eliminated. The patient no longer has breast
discom ort and can com ortably lie in the prone position.

Chapter 5 • Capsular Contracture After Augmentation

65
Manual compression o the breasts reveals that they are much so ter and signi -
cantly more compliant (Baker grade I).

Part II: Problems in Augmentation Mammaplasty
66
TEACHING PO INTS
This case illustrates a di cult subgroup o breast implant patients who have re-
ractory capsular contracture. Many o these patients have undergone repeated
attempts at correction. Despite a variety o surgical maneuvers and methods, con-
tracture sometimes recurs within months o their revision procedure. Repeated
capsulotomies and capsulectomies and the sometimes injudicious insertion o pro-
gressively larger prostheses make these patients susceptible to atrophy and thinning
o the so t tissues o the breast. Waviness, rippling, and implant palpability can re-
sult rom insu cient so t tissue coverage. Damage to the so t tissue envelope can be
so severe that some patients require importation o healthy tissues rom a distant
site, most o ten a latissimus dorsi muscle f ap; ADMs may also be e ective.
In this patient, a multi aceted approach, with attention to reducing the risk o bac-
terial bio lm ormation, was a reasonable course o action. The patient was ully
in ormed o her relatively poor prognosis or permanent eradication o contracture
and her cosmetic limitations, especially because o her so t tissue de ciency.
The postoperative result achieved in this case was a de nite improvement. Her
breasts were signi cantly so ter and more compressible, her cleavage improved, and
there was a dramatic reduction o the spherical de ormation that accompanies ad-
vanced contracture. Her cosmetic result, however, was ar rom ideal. Because o
repeated operations, she does not have adequate so t tissue to completely camou-
f age the implant; she has subtle so t tissue irregularities, residual breast asymmetry,
and persistent retraction o her periareolar scars. Yet the patient reports that she is
“very satis ed” with her result. Additional monitoring over time is the only way to
prove whether there will be long-term alleviation o her capsular contracture.
BIBLIO GRAPHY
Adams WP Jr, Conner WC, Barton FE Jr, et al. Optimizing breast pocket irrigation: an in vitro study
and clinical implications. Plast Reconstr Surg 105:334-338, 2000.
Collis N, Coleman D, Foo IT, et al. Ten-year review o a prospective randomized controlled trial o
textured versus smooth subglandular silicone gel breast implants. Plast Reconstr Surg 106:786-
791, 2000.
Collis N, Sharpe DT. Recurrence o subglandular breast implant capsular contracture: anterior versus
total capsulectomy. Plast Reconstr Surg 106:792-797, 2000.
Handel N. Managing complications o augmentation mammaplasty. In Spear SL, ed. Surgery o the
Breast: Principles and Art, 3rd ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins,
2011.
Handel N, Jensen JA, Black Q, et al. The ate o breast implants: a critical analysis o complications
and outcomes. Plast Reconstr Surg 96:1521-1533, 1995.
Huang CK, Handel N. E ects o Singulair (montelukast) treatment or capsular contracture. Aesthet
Surg J 30:404-410, 2010.
Rohrich RJ, Kenkel JM, Adams, WP. Preventing capsular contracture in breast augmentation: in
search o the Holy Grail. Plast Reconstr Surg 103:1759-1760, 1999.

5c Implant Removal, Tissue Expansion, and Replacement
With Contoured Gel Implants
Dav id a . Ca pl in
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 41-year-old woman had undergone a subglandular breast augmentation, per-
ormed elsewhere, 2 years earlier. Available records showed that 300 cc round sili-
cone gel implants were placed through an in ramammary approach. She is a ormer
bodybuilder and is currently a personal trainer. She noted rippling and downward
migration o her implants within the rst year a ter her surgery. Her nipples tended
to show above her bathing suit and bra line. She pre erred larger implants and
wanted to use highly cohesive implants i possible. She was willing to undergo a
staged procedure and to have her implants moved to a submuscular position.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
This patient’s NAC sat 17.5 cm rom the suprasternal notch on the right and
18 cm on the le t. The IMF-to-nipple distances measured 13.5 cm on the right and
13.5 cm on the le t. There was less than 3 cm o so t tissue pinch in the upper pole
o both breasts. The nipples were positioned very high on the breast mound and
encroached on her tan lines. There was bilateral palpable and visible rippling in-
eromedially and superomedially. She was extremely thin, had signi cant pectoralis
development, was 5 eet 7 inches tall, and weighed 125 pounds. There were mature
in ramammary scars and grade II capsules.
ANALYSIS O F THE PRO BLEM
This patient requested larger implants with correction o the position o the IMFs
and o the nipples on the breast mound. She had almost no breast tissue, so a sub-
glandular exchange would not have been a good option unless ADM was used to
cover the implants. Removal o the implants (without replacement) with a capsu-
lectomy and a secondary procedure or submuscular implant placement was dis-
cussed with the patient. However, it was elt that as a result o her pronounced
67

Part II: Problems in Augmentation Mammaplasty
68
pectoralis muscle development, it would be di cult to place a larger implant in a
submuscular position even as a secondary procedure, and she would not agree to
removal without some orm o immediate replacement. Reestablishing the IMF
position as part o a single-stage procedure would have been challenging, even i
the patient were willing to accept a smaller implant size. Her desire to have larger,
highly cohesive implants was a major consideration in the preoperative planning.
She was willing to undergo a two-stage procedure, so a total subglandular capsu-
lectomy and submuscular placement o tissue expanders was chosen as the rst o
two procedures.
RECOMMENDED SOLUTION TO THE PROBLEM
FIRST STAGE
Total subglandular capsulectomy through existing in ramammary scars
Placement o submuscular Mentor Siltex 350 cc medium-height tissue expanders
positioned so that the base was at the level o the desired new IMF
Gradual expansion to 350 cc
SECO ND STAGE
Capsulotomy with strip-capsulectomy to provide a raw sur ace to inter ace with
the textured MemoryShape implants
Use o sizers with the patient in the erect position
Precise dissection o submuscular pockets to the exact dimension or the chosen
355 cc style MM implants
Placement o drains be ore closure, use o Ioban sheeting, back-f ushing through
drains with antibiotic concentrate, and use o Biopatches around the drains
TECHNIQ UE FO R THE FIRST STAGE
RIGHT SIDE
A total subglandular capsulectomy and placement o a tissue expander in the sub-
muscular position was per ormed. The pectoralis muscle was sutured to the overly-
ing breast tissue to prevent herniation o the expander into the subglandular space.

Chapter 5 • Capsular Contracture After Augmentation

69
LEFT SIDE
The procedure was repeated in similar ashion. The base o the tissue expander was
positioned at the level o the desired new IMF in each breast. A drain was placed,
Ioban sheeting applied, and the Mentor Siltex 350 cc medium height tissue expand-
ers were positioned and closures per ormed in layers. Antibiotic concentrate was
back-f ushed through the drains at the completion o the layered closures. The ex-
panders were lled to 180 cc and then progressively lled to 350 cc over a period
o 4 weeks.
TECHNIQ UE FO R THE SECO ND STAGE
RIGHT SIDE
An incision was made just above the level o the IMF, which had been created by
the position o the tissue expander. An extensive capsulotomy and partial capsulec-
tomy were per ormed to create a raw sur ace to inter ace with the textured sur ace
o the implant and to allow tailoring o the pocket dimensions. MemoryShape siz-
ers were used with the patient in the erect position, and a style MM 355 cc Memo-
ryShape implant was chosen.
LEFT SIDE
The procedure was repeated in similar ashion. A drain was placed in each breast,
Ioban sheeting was used to cover the breasts be ore the MemoryShape style MM
355 cc implants were positioned with a no-touch technique, and antibiotic concen-
trate was back-f ushed through the drains. A ter completion o the layered closures,
a Biopatch was applied around each o the drains.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The 5-year postoperative photos show a nice correction o the IMF position with
an appropriately increased implant volume and a natural shape bilaterally.

Part II: Problems in Augmentation Mammaplasty
70
Good symmetry has been reestablished and the NAC position has been normalized.
Grade I capsules were noted on long-term ollow-up.
TEACHING PO INTS
There are a number o ways this problem could have been addressed. However, this
case was complicated by the extreme degree to which the implants had descended
below the native IMF as well as by this patient’s limited amount o breast tissue
and her muscular build. The use o tissue expanders provided an easy and reliable
way to reestablish the IMF and expand a thick pectoralis muscle, allowing a airly
straight orward second-stage procedure.
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