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

Part II: Problems in Augmentation Mammaplasty
72
having a mastopexy because she did not want additional scars on her chest. She
requested bigger implants. The patient was postmenopausal and was not receiving
hormone replacement therapy. She was a healthy nonsmoker with no signi cant
medical issues.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
This patient demonstrates one o the most common key drivers to reoperations a -
ter breast augmentation. The presenting problem is complex and requires thought-
ul planning and execution, because her risk or needing reoperation or a uture
capsular contracture will remain high. The patient most likely has one o the third-
generation silicone implants with thin shells and less cohesive silicone. Because
this implant is under the muscle, her so t tissue can be used to determine whether
a mastopexy should be per ormed. This is unlike an implant in a subglandular
pocket.
ANALYSIS O F THE PRO BLEM
When evaluating a complicated case, we should systematically evaluate all lay-
ers involved in shaping the breast. By using this systematic method, as described in
Chapter 5e, one critical decision will be what to do with the existing capsule. Be-
cause the patient probably has third-generation silicone implants and a rupture is
suspected, either the capsule should be removed or a neopectoral pocket should be
created by collapsing the capsule. The decision must be made intraoperatively, be-
cause the major determinant o total capsulectomy would involve whether calci ca-
tion is present within the capsule. A so t tissue manipulation (mastopexy) may not
be needed based on the current status o her skin, which is completely dissociated
rom the implant pocket by the pectoralis major muscle. Once a dual-plane pocket
is planned, better shaping o the lower pole will create a more aesthetically pleasing
breast orm.
RECOMMENDED SOLUTION TO THE PROBLEM
Revision augmentation with silicone implants:
– Site change to a neopectoral pocket, with or without mastopexy
– Site change to neopectoral pocket with ADM, with or without mastopexy
– Total capsulectomy, with or without mastopexy
– Total capsulectomy site change to a subglandular placement, with or without
mastopexy

Chapter 5 • Capsular Contracture After Augmentation

73
TECHNIQ UE
The revision procedure was per ormed through the in ramammary incision. The
origins o the pectoralis were identi ed and released, and access was obtained in a
plane between the anterior capsule and the pectoralis major. When the capsule was
entered, rupture o the silicone implants was noted. All contents were moved and
rinsed multiple times. The capsule was examined; no calci cations were present.
The neopectoral pocket was developed to reset the dimensions o the new breast.
Once the decision was made to keep the capsule, the old pocket was washed with
triple-antibiotic solution and the area allowed to soak or at least 5 minutes to en-
sure e ective bactericidal action. Then the pocket was closed with multiple inter-
rupted sutures. Sizers were placed and once the nal size was chosen, the ADM
(Strattice) was anchored cephalad to the released pectoralis major with 3-0 Vicryl
sutures.

Part II: Problems in Augmentation Mammaplasty
74
The nal implants were then placed into the pocket, and the caudal edge o the
ADM was anchored to the chest wall and Scarpa’s ascia at the IMF. A drain was
placed and Scarpa’s ascia was closed with 3-0 Vicryl, ollowed by intradermal 4-0
Vicryl and 4-0 Monocryl.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The postoperative photos o this patient at 16 months a ter her secondary proce-
dure show aesthetically pleasing, so t results.
Implant placed
in neopectoral pocket
Previous pocket
collapsed and
sutured to chest wall
Pectoralis
muscle sutured
to ADM
ADM sutured
to IMF

Chapter 5 • Capsular Contracture After Augmentation

75
The highest risk o recurrence o capsular contracture is during the rst 12 postop-
erative months, especially the rst 6 months. There is no guarantee that the capsule
will not re orm in the uture, but once we are past the critical rst year, the risk is
signi cantly reduced.

Part II: Problems in Augmentation Mammaplasty
76
TEACHING PO INTS
Anytime we are planning a revision procedure, it is important to ollow the core
principles o breast surgery. Every e ort is made to maximize outcomes and mini-
mize reoperative complications. The most important decision in this case was
whether to keep the capsule or remove it. Removal o a subpectoral capsule has its
own complications and morbidities. In ormed consent should include the possibil-
ity o staging i severe calci cations are present and a total subpectoral capsulec-
tomy is needed and we are unable to create a stable pocket. Although we attempt
to per orm such cases in a single operation, i staging is planned, the second stage is
not considered a complication but a planned return to the operating room to com-
plete the revision augmentation.
Because the capsule in this case was not calci ed and all ruptured silicone contents
were removed, we decided to keep the capsule and create the neopectoral pocket.
Soaking the capsule or a prolonged time (more than 5 minutes) to ensure the bac-
tericidal activity o the dissolved antibiotics is important to decontaminate the
pocket.
BIBLIO GRAPHY
Colwell AS, Breuing KH. Improving shape and symmetry in mastopexy with autologous or cadaveric
dermal slings. Ann Plast Surg 61:138-142, 2008.
Kau man D. Pocket rein orcement using acellular dermal matrices in revisionary breast augmentation.
Clin Plast Surg 39:137-148, 2012.
Maxwell GP, Gabriel A. The neopectoral pocket in revisionary breast surgery. Aesthetic Surg J 28:463-
467, 2008.
Maxwell GP, Gabriel A. Use o the acellular dermal matrix in revisionary aesthetic breast surgery. Aes-
thetic Surg J 29:485-493, 2009.
Namnoum JD, Moyer HR. The role o acellular dermal matrix in the treatment o capsular contrac-
ture. Clin Plast Surg 39:127-136, 2012.

5e Revision Augmentation With Total Explantation, Site
Change, and Insertion of Silicone Implant With ADM
a l l en Ga br iel , G. pa t r ic k Ma x w el l
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 36-year-old woman had one previous breast augmentation 14 years earlier
with subglandular saline implants. Over the years, the patient developed pain ul
capsular contracture with discom ort and de ormity. To treat this problem, she was
advised to continue to massage the breasts and take za rlukast (Accolate), which
did not improve her symptoms. The patient was interested in having a revision to
alleviate her discom ort and to make her breasts smaller. She was a healthy non-
smoker with no signi cant medical issues.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
This patient demonstrates one o the most common key drivers to reoperations
ollowing breast augmentation. The presenting problem is complex and requires
thought ul planning and execution because her risk or reoperation or a uture
capsular contracture remains high. The patient appears to have thin lax tissue over-
lying the implant and currently the capsular contracture is holding the skin taut
and the nipples in a central position. Release or removal o the capsule will create
an even more di cult problem than capsular contracture: the breast tissue will go
rom rm to lax. This must be recognized preoperatively, and the patient must be
advised o the possible necessity o a mastopexy to reshape the so t tissue envelope.
ANALYSIS O F THE PRO BLEM
When evaluating a complicated case, one must systematically evaluate all layers in-
volved in shaping the breast. We use a systematic method much like the ones used
in acial ractures: going either rom “outside in or inside out.” We will evaluate
this patient rom inside out. She has minimal chest wall de ormity rom a worm’s
eye view. One can notice a slightly sharper drop-o laterally on the right side o
77

Part II: Problems in Augmentation Mammaplasty
78
the chest compared with the le t side. As witnessed in our asymmetry study, this is
a very common nding in all patients. Most likely, the le t side o the chest is more
convex rom an embryologic development, because the heart is under the le t rib
cage, causing the ribs to protrude more on that side.
The next layer to be analyzed is the muscle. The implant is in a subglandular posi-
tion, so the muscle has not been violated and will be used or the site change opera-
tion or a dual-plane approach. Then we will analyze the capsule. Because o the
extent o capsular contracture, both the anterior and posterior capsule will have to
be removed. The implant will be removed in conjunction with the capsule, with the
hope o removing the entire complex as one entity. Once the implant and the an-
terior and posterior capsules are removed, we must consider what we will do with
the last layer, which is the so t tissue envelope. In this case, a so t tissue reduction
will be planned because o the laxity o the skin that is already present.
RECOMMENDED SOLUTION TO THE PROBLEM
Revision augmentation with total capsulectomy and placement o silicone im-
plant in:
– Subglandular position, with or without mastopexy
– Dual-plane position, with or without mastopexy
– Dual plane with ADM, with or without mastopexy
TECHNIQ UE
The revisionary procedure was per ormed through an in ramammary incision. To-
tal capsulectomy, including removal o the implant, was per ormed on each side.

Chapter 5 • Capsular Contracture After Augmentation

79
A dual-plane pocket was prepared by releasing the origins o the pectoralis major.
Sizers were placed and tailor-tacking was per ormed; once the size was con rmed,
the ADM (Strattice) was anchored cephalad to the released pectoralis major with
3-0 Vicryl sutures.
The implants were then placed into the pocket and the caudal edge o the ADM
was anchored to the chest wall and Scarpa’s ascia at the IMF.
Deepithelialized skin
Pectoralis
major cut
ADM sutured
to IMF
Implant
Original subglandular
implant location
Inframammary
incision
Deepithelialized
skin
Pectoralis
muscle sutured
to ADM
ADM
sutured to IMF
Implant

Part II: Problems in Augmentation Mammaplasty
80
Then the tailor-tacking areas were deepithelialized and the superior pedicle was es-
tablished or the NAC.
A ter removal o the excess breast tissue (10 g rom each side), vertical pillar clo-
sure or shaping the breast was approximated with 2-0 Vicryl. The horizontal, ver-
tical, and periareolar incisions were closed with 4-0 Vicryl and 4-0 Monocryl, and
drains were placed on each side.

Chapter 5 • Capsular Contracture After Augmentation

81
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The postoperative photos o this patient a ter her secondary procedure show aes-
thetically pleasing results. At 18-month ollow-up, her vertical scar is slightly dis-
colored but it does not concern the patient, because she now has so t breasts that
are more appropriate or her shape and size.
Preoperative
6 months postoperatively
18 months postoperatively

Part II: Problems in Augmentation Mammaplasty
82
TEACHING PO INTS
When tackling a complex revisionary case, it is recommended to ollow the core
principles o breast augmentation and to evaluate the case in detail. Every e ort
must be made to minimize a return to the operating room in the uture. Capsular
contracture has a higher chance o recurrence; there ore ADM can be use ul. Al-
though there are no randomized controlled trials to support the use o ADM in re-
ducing capsular contracture, there are multiple case series with long ollow-up that
have well-documented outcomes with the use o ADM (Strattice) in treating and
preventing the development o capsular contracture.
A site change principle in these complicated cases is also advised, because it is im-
portant to rede ne the breast orm by recreating the natural-appearing dimensions.
Whether it’s a site change rom subglandular to dual plane or rom a submuscular
to neopectoral pocket, it is important to use ADM in both cases. The solution is to
avoid placing an implant in a pocket where the capsule has been removed and the
tissue is even more lax. Placing the implant in such a pocket would result in an aes-
thetically unsatis actory shape.
BIBLIO GRAPHY
Adams WP Jr. Capsular contracture: what is it? What causes it? How can it be prevented and man-
aged? Clin Plast Surg 36:119-126, 2009.
Adams WP Jr, Rios JL, Smith SJ. Enhancing patient outcomes in aesthetic and reconstructive breast
surgery using triple antibiotic breast irrigation: six-year prospective clinical study. Plast Reconstr
Surg 117:30-36, 2006.
Maxwell GP, Gabriel A. Use o the acellular dermal matrix in revisionary aesthetic breast surgery. Aes-
thet Surg J 29:485-493, 2009.
Wiener TC. Relationship o incision choice to capsular contracture. Aesthetic Plast Surg 32:303-306,
2008.
Wong CH, Samuel M, Tan BK, Song C. Capsular contracture in subglandular breast augmentation
with textured versus smooth breast implants: a systematic review. Plast Reconstr Surg 118:1224-
1236, 2006.

6a Two-Stage Salvage With Placement
of Smaller Implants
Nea l Ha n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 27-year-old mother o one child underwent an elective breast augmentation
3 weeks previously. Her surgeon inserted 350 cc submammary silicone gel implants
through crescent mastopexy incisions. The patient received prophylactic cepha-
lexin (Ke ex) or 5 days. Her early postoperative course was unremarkable; how-
ever, approximately 1 week a ter surgery, she experienced dehiscence o the upper
c H a Pt e r 6
IMPENDING IMPLANT EXPOSURE/
EXTRUSION
83

Part II: Problems in Augmentation Mammaplasty
84
portion o the crescent incision o the le t breast. Her surgeon per ormed a delayed
secondary closure under local anesthesia and started the patient on a second course
o oral antibiotics (azithromycin). Within another week, the patient noticed a slight
amount o serous drainage rom the wound; this was ollowed within days by re-
current wound breakdown. She was re erred or treatment o “dehiscence o her
surgical incision.”
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient is a healthy-appearing Hispanic woman. Examination reveals recurrent
breakdown o the le t crescent incision; a 1.5 by 2 cm oval-shaped open wound ex-
tends between the 12 o’clock to 3 o’clock positions on the border o the areola. The
area is characterized by healthy-appearing granulation tissue with a central f stula
that is presumed to communicate with the periprosthetic space. In addition, an ir-
regularly shaped 1.5 by 3 cm area o atrophic, desquamating skin is noted over the
lower medial quadrant o the le t breast. The skin is extremely attenuated, with
only 1 to 2 mm o so t tissue coverage over the implant. The area appears dark be-
cause the thinned skin is translucent, revealing the underlying silicone implant. The
right breast is healing satis actorily.
ANALYSIS O F THE PRO BLEM
Early a ter primary augmentation mammoplasty, this patient presented with wound
dehiscence. Despite an attempt to debride and close the wound secondarily, she
experienced recurrent separation. More o ten than not, persistent ailure o an in-
cision to heal is indicative o underlying in ection. In this case the severe thinning
o the so t tissues o the lower medial quadrant was urther evidence o progres-
sive in ection with involvement o the periprosthetic pocket. Cultures o the wound
proved negative, but that is not unusual when patients have been on oral antibiot-
ics. It is likely that bacterial growth had been suppressed to levels that made it di f -
cult to obtain positive cultures, but the low-grade indolent in ection persisted, caus-
ing thinning and atrophy o the tissues, particularly in the dependent portions o
the breast. The patient was advised that this was an “urgent” problem requiring im-
mediate intervention due to the imminent risk o implant exposure and extrusion.
Implant salvage was not a viable option because o the extent o so t tissue damage.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o le t breast implant
Debridement o necrotic tissue
Curettage and pulse lavage o capsule
Insertion o suction drain and closure o incision
Explantation and drainage o contralateral breast, i elected by patient
Delayed reimplantation a ter an appropriate interval

Chapter 6 • Impending Implant Exposure/Extrusion

85
TECHNIQ UE
The in ected implant was removed through the original operative incision; the cap-
sule was curetted by abrading the sur ace with a scrub brush and the pocket pulse-
lavaged with 2 L o double antibiotic (neomycin and bacitracin) irrigation solution.
A 7 mm at Jackson-Pratt drain was placed and the incision closed primarily. The
contralateral implant was removed and the pocket drained. Both breasts healed
unevent ully. The patient had some residual induration, skin irregularity, and dis-
coloration o the lower inner quadrant o the le t breast. A ter initial healing was
complete 6 weeks later, the patient was instructed to begin massaging the le t breast
to break up adhesions in preparation or reinsertion o new implants. Four months
a ter explantation, we believed that reinsertion o new implants could sa ely be un-
dertaken so the patient returned to surgery. Through her existing crescent masto-
pexy scars, a subpectoral pocket was dissected on each side. Moderate plus prof le
round silicone gel implants were inserted. Slightly smaller implants were used than
those in her original surgery; a 275 cc implant was inserted on the right side and a
300 cc implant on the le t to compensate or the loss o tissue due to in ection. The
patient’s postoperative course was unremarkable.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 3 months a ter reinsertion o the implants. The breasts are
closely symmetrical in volume and shape. The patient has not developed capsular
contracture on either side. There is slight areolar de ormity in the area o the previ-
ous dehiscence.

Part II: Problems in Augmentation Mammaplasty
86
Subtle hyperpigmentation and slight sur ace irregularities are visible in the lower
inner quadrant o the le t breast. The patient is very satisf ed with her f nal out-
come.
TEACHING PO INTS
This case illustrates the act that when there is wound separation and dehiscence o
the surgical incision in the presence o a breast implant, it is o ten underlying in ec-
tion that is contributing to delayed healing. Some postoperative in ections can be
eradicated without explantation. I a patient presents with cellulitis but the peri-
prosthetic space is not involved, oral antibiotics alone may su f ce. Even in cases
where the pocket has become contaminated, salvage is still possible with explanta-
tion, vigorous pocket lavage, insertion o a new prosthesis, and parenteral antibiot-
ics. But in a case such as this, attempting implant salvage is ill-advised. As a result
o the duration o the in ection, there was already signif cant tissue thinning and
irreversible skin damage. Immediate explantation was indicated to prevent urther
tissue erosion and possible implant extrusion. A ter a suitable waiting period, usu-
ally 3 to 6 months, the tissues generally recover enough that reimplantation can
sa ely be per ormed.
BIBLIO GRAPHY
De Lorenzi C. Success ul treatment o acute periprosthetic breast in ection with curettage, pulse la-
vage, and immediate device exchange. Aesthetic Plast Surg 29:400-403, 2005.
Khan UD. Breast augmentation, antibiotic prophylaxis, and in ection: comparative analysis o 1,628
primary augmentation mammoplasties assessing the role and e f cacy o antibiotics prophylaxis
duration. Aesthetic Plast Surg 34:42-47, 2010.
Pittet B, Montandon D, Pittet D. In ection in breast implants. Lancet In ect Dis 5:94-106, 2005.
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.

6b Management of Impending Saline Implant Exposure
Resulting From Intraluminal Steroids
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
Four years be ore being seen, this patient had bilateral saline implants placed sub-
glandularly at age 24. At initial evaluation at age 28, the patient complained o
marked thinning o the skin, most signif cantly on her le t side and that the saline
implants looked like they are about to come through her skin. She reported that the
le t implant continued to drop down and that in the last year, the skin over the le t
implant had taken on a blue color below the nipple. She stated that the original sur-
geon told her that he put medicine in the saline implant to prevent it rom getting
hard, but she did not recall what type o medicine he used. She stated that she had
very little breast tissue be ore the augmentation and requested augmentation with
implants i at all possible.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The le t implant is visible under a very thin layer o skin on the entire lower hal
o the breast. The skin medial to the le t implant has also thinned out, with only a
thin layer o dermis covering the implant. Wrinkling o the saline implant is visible
and palpable both medially and in eriorly. The blue discoloration along the lower
pole o the le t breast is a result o the Tyndall e ect. The right breast also has some
thinning o the overlying tissue, but less than that o the le t.
There is no signif cant breast tissue below the le t NAC. On the le t medial breast
near the sternum, the implant appears to be almost eroding through the skin, and
there is no capillary ref ll o this thinned-out overlying tissue. The le t medial skin
has partially elevated o the sternum, indicating the beginning o synmastia.
87

Part II: Problems in Augmentation Mammaplasty
88
ANALYSIS O F THE PRO BLEM
Most likely steroids were placed inside these saline implants during the original
augmentation. In the 1970s it was thought that adding steroids to saline implants
might reduce the incidence o capsular contracture. However, there has not been
any data on the appropriate dosage o steroids, and the practice no longer exists.
Also, since the silicone shell o a breast implant is semipermeable, it is possible or
the steroid to leech out o the shell and invade the surrounding breast tissue; or
this woman, this has led to signif cant thinning o the overlying skin, with impend-
ing erosion o the implant on the le t side.
At the time, the only option was to remove the implants and possibly some o the
overlying skin. It was essential to allow the skin and so t tissue time to recover be-
ore considering any reconstructive options.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o both implants with possible skin excision
Waiting several months and then recontouring the le t skin envelope by excising
any remaining severely damaged skin
Waiting an additional 6 months be ore per orming submuscular breast augmen-
tation with conservative-sized gel implants
TECHNIQ UE
The original implants were removed through
in ramammary incisions. An ellipse o skin,
which was markedly thinned out along the
lower pole o the le t breast, was also re-
moved.

Chapter 6 • Impending Implant Exposure/Extrusion

89
The patient’s skin was then allowed to heal and contract. A ter 6 months, the pa-
tient returned to the operating room, where skin resection and modif cation was
per ormed, removing the skin medially and excising the most damaged so t tissues.
Six months later, bilateral submuscular augmentation with gel implants was per-
ormed using an in ramammary incision. It was apparent that the steroids used in
the original augmentation had also a ected the pectoralis muscle, which appeared
thinner than normal. Small 275 cc implants were selected to minimize the pressure
on the overlying tissue.
The patient did well or 2 years but
then returned with partial recur-
rence o the original problem on
the le t side, where the implant had
migrated both medially and in eri-
orly. The right side was stable with
no urther problems.

Part II: Problems in Augmentation Mammaplasty
90
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
At 2-year ollow-up, the f nal revision procedure has proved success ul.
This case is an example o the importance o having realistic expectations or both
the patient and doctor. Signif cant damage o the overlying so t tissue has compro-
mised the f nal results. The other option o bringing in new tissue or skin replace-
We removed the le t implant and the capsule that
had now ormed a ter the submuscular placement
was used to close the pocket medially and in eriorly
with permanent sutures. The IMF was slightly over-
elevated using suture f xation, because we expected
some in erior displacement over time. In addition,
at the time o this f nal revision, relatively small
275 cc implants were placed.

Chapter 6 • Impending Implant Exposure/Extrusion

91
ment, such as a latissimus dorsi ap, would have created a donor scar; however,
this was still a very reasonable option, especially i only muscle were used. I the de-
cision was made to replace the skin, then a myocutaneous ap, in conjunction with
ADM, would be another good option.
TEACHING PO INTS
So t tissue distortion rom steroids can continue to have e ects or months or even
years a ter the steroids are used. The use o steroids in saline implants probably cre-
ated more problems than solutions. The ability o steroids to reduce capsule orma-
tion was not studied in any controlled ashion. This patient had signif cant damage
not only to the overlying skin and breast tissue but also probably to the tissue that
was deep to the implant.
It was only a ter the patient developed a capsule a ter the new submuscular im-
plants were placed that it was possible to correct the recurrence o her implant mal-
position, using the capsule as support.
This case was per ormed several years ago; today many would use ADM to rein-
orce the lower pole o the le t breast. However, at the time o conversion to sub-
muscular implants, the recovered overlying tissue appeared adequate, and the re-
currence o implant malposition was unexpected. Another option was a latissimus
dorsi ap; however, this patient did not want additional scars, and that would not
be the f rst option in a young individual.
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.
Brandstetter M, Schoeller T, Pülzl P, et al. Capsular ap or coverage o an exposed implant a ter skin-
sparing mastectomy and immediate breast reconstruction. J Plast Reconstr Aesthet Surg 63:1388-
1390, 2010.
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.
Munhoz AM, Gemperli R. Discussion: Management o the in ected or exposed breast prosthesis: a
single surgeon’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, 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.

6c Impending Implant Exposure Treated by Explantation
and Delayed Fat Grafting With Implant Reinsertion
Nea l Ha n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 52-year-old woman was re erred or breast revision by a local plastic surgeon.
She had a long, complicated history concerning her breasts. The patient had under-
gone breast augmentation about 15 years previously, with subpectoral saline im-
plants inserted though periareolar incisions. She had two revisions by her original
plastic surgeon or implant malposition and pain. Later, another plastic surgeon
inserted larger-volume silicone gel implants. She subsequently noted waviness and
rippling o her breasts and sought treatment rom a third plastic surgeon, who told
her he wanted to “redo everything rom scratch.” He removed her old implants and
replaced them with new 275 cc moderate plus prof le smooth gel implants in the
submammary position. He placed a Strattice ADM gra t on the right side and per-
ormed bilateral circumareolar mastopexies.
The patient presented 8 months a ter the last operation complaining o breast
asymmetry, ptosis, nipple-areolar asymmetry, waviness that was especially notice-
able when she leaned orward, and lateral implant malposition that was most ap-
parent when she was lying supine. Measurements revealed the areolar diameter on
92

Chapter 6 • Impending Implant Exposure/Extrusion

93
the right side was 6 cm and the areolar diameter on the le t was 4.5 cm. The Strat-
tice gra t on the right side appeared to have torn loose and rolled upon itsel ; it
was palpable as a f rm, thick ridge running subcutaneously along the in eromedial
portion o the right breast. The patient requested revision to correct all o these
problems. I decided to per orm a combination o procedures designed to address
as many o the patient’s concerns as possible. She underwent bilateral asymmetri-
cal Benelli mastopexies, removal o the rolled-up lump o ADM, and bilateral con-
version o her same silicone gel implants rom submammary to subpectoral. Large
Strattice gra ts were placed bilaterally, spanning rom the lateral border o the pec-
toral muscle to the IMF, to prevent “window shading” o the pectoral muscle and
to rein orce the in erior pole o each breast.
The surgical procedure itsel was unremarkable, and the patient had a good post-
operative result at 6 weeks.
About 2 weeks later (8 weeks postoperatively), she presented with erythema, ten-
derness, and uctuance o the lower inner quadrant o her right breast. It was evi-
dent she had an in ection. She was started empirically on 800 mg sul amethoxazole
and 160 mg trimethoprim (Bactrim DS) twice daily and levo oxacin (Levaquin)
500 mg per day. When the patient was seen 48 hours later, there was no improve-
ment; in act, the tissues appeared thinner, with threatened skin erosion and im-
plant exposure. The patient was in ormed that explantation was the most prudent
course. She elected to have both implants removed.

Part II: Problems in Augmentation Mammaplasty
94
The patient rejected any surgery that would result in donor scars and wanted the
“least aggressive” approach that had a reasonable chance o success. She agreed to
undergo a series o autologous at trans ers to the thinned-out tissues o the right
breast, to be ollowed by reinsertion o silicone implants.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
ANALYSIS O F THE PRO BLEM
This patient has severe breast de ormity, signif cant so t tissue def ciency, and exten-
sive scarring as a result o ailed breast implant surgery. The so t tissues are most
severely compromised in the lower inner quadrant o the right breast, in the area
where there was threatened erosion o the implant through the skin.
RECOMMENDED SOLUTION TO THE PROBLEM
Massage o the breasts and ultrasound to break down adhesions
Multistaged autologous at gra ting
Insert new implants when so t tissues have su f ciently recovered
At surgery it was noted that most o the ADM was adherent to the
adjacent tissues; both implants were removed, and the ADM that was
not incorporated into the patient’s tissue was excised. The pocket was
pulse lavaged with 3 L o double antibiotic solution (Bacitracin and
Neomycin), and suction drains were inserted. The patient’s recovery
was unevent ul; her appearance is shown at 1 month a ter explanta-
tion. The patient was understandably dissatisf ed with her appearance
and requested urther attempts at reconstruction. Second opinions
were sought rom several other plastic surgeons: the patient received a
range o recommendations, rom latissimus dorsi reconstruction to an
endoscopic trans er o a pedicled omental ap.
The patient is seen 6 months a ter bilat-
eral explantation. She has signif cant de-
ormity o the breasts bilaterally. There is
a severe def ciency o subcutaneous tissue,
particularly in the lower inner quadrant o
the right breast, where the dermis is f rmly
adherent to underlying structures.

Chapter 6 • Impending Implant Exposure/Extrusion

95
TECHNIQ UE
The patient waited 6 months a ter her explantation be ore proceeding with urther
surgery. During that time she was very compliant about massaging the area and
received ultrasound treatments; there was substantial so tening o the tissues. She
then underwent her f rst session o autologous at gra ting. Fat was harvested rom
the hip roll area, and 30 cc was gra ted into the most depressed areas o the in ero-
medial right breast. Three months later, in a second at gra ting session an addi-
tional 30 cc o at was trans erred rom an inner thigh donor site to the lower inner
quadrant o the right breast.
The patient waited 3 more months, then we inserted a new pair o shaped silicone
implants in the subpectoral plane. At the time o reinsertion o implants, the so t
tissues o the lower inner right breast were dramatically improved as a result o at

Part II: Problems in Augmentation Mammaplasty
96
gra ting; intraoperatively it was noted that the Strattice ADM gra t placed earlier
was solidly integrated into the tissues, and this provided an extra layer o coverage
over the prosthesis. Her postoperative course was unevent ul.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient’s appearance is shown 6 months a ter insertion o shaped silicone
breast implants. Although there is subtle asymmetry and slight dimpling o the skin
at the site o threatened implant erosion, the patient is very pleased with her ap-
pearance. She has resumed all previous activities and is com ortable in any type o
clothing. She is also completely satisf ed with her appearance when unclothed.

Chapter 6 • Impending Implant Exposure/Extrusion

97
TEACHING PO INTS
This patient, who had undergone a series o prior breast procedures, initially ap-
peared to have a success ul result a ter conversion o implants rom submammary
to subpectoral, insertion o ADM gra ts, and bilateral periareolar mastopexies.
However, 2 months a ter surgery she developed an in ection that was unresponsive
to antibiotics and caused progressive thinning o the dependent portion o the right
breast. Erosion o the skin with implant extrusion was imminent. This necessitated
urgent explantation and removal o portions o the ADM that were not yet ully in-
corporated. While ADMs play an increasingly important role in revision breast sur-
gery, these products are associated with an increased risk o seroma, an increased
risk o in ection, and an increased risk o explantation. In patients such as this, who
have insu f cient so t tissue, extensive scarring, and a marginal blood supply, the
traditional approach has been to recruit healthy, well-vascularized tissue rom an-
other location, principally with pedicled or ree aps. However, in recent years au-
tologous at gra ting has provided a relatively easy, reliable technique or improving
the condition o atrophic, scarred tissues. There is still debate about the precise role
o stem cells in this process, but there is no doubt that the physical condition o the
skin and subcutaneous tissues in a damaged region o the breast can be signif cantly
improved by at gra ting. In this case, two sessions o at gra ting enabled success ul
insertion o new prostheses and obviated the need or distant aps requiring inva-
sive procedures and potentially resulting in donor site morbidity.
BIBLIO GRAPHY
Choi M, Small K, Levovitz C, et al. The volumetric analysis o at gra t survival in breast reconstruc-
tion. Plast Reconstr Surg 131:185-191, 2013.
de Blacam C, Momoh AO, Colakoglu S, et al. Evaluation o clinical outcomes and aesthetic results
a ter autologous at gra ting or contour de ormities o the reconstructed breast. Plast Reconstr
Surg 128:411e-418e, 2011.
Hanna KR, DeGeorge BR Jr, Mericli AF, et al. Comparison study o two types o expander-based
breast reconstruction: acellular dermal matrix-assisted versus total submuscular placement. Ann
Plast Surg 70:10-15, 2013.
Ho G, Nguyen TJ, Shahabi A, et al. A systematic review and meta-analysis o complications associated
with acellular dermal matrix-assisted breast reconstruction. Ann Plast Surg 68:346-356, 2012.
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)

7a Pocket Modif cation With Insertion o Silicone
Gel Implants
Nea l Ha n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 38-year-old woman returned to me 11 years a ter undergoing subpectoral
augmentation with saline- lled implants. Her original surgery was per ormed with
smooth round inf atable implants inserted through a periareolar approach; the op-
eration was unevent ul, and the patient was happy with her result. The patient sub-
sequently became pregnant and had one child, now 5 years old. She remained satis-
ed with the result o her breast augmentation until about 6 months ago, at which
C H a p t e r 7
DEFLATED SALINE IMPLANTS
99

Part II: Problems in Augmentation Mammaplasty
100
time she noted the spontaneous onset o gradual loss o volume o the le t breast.
The patient suspected this was caused by a “leaking” implant. Review o her old
operative report revealed her implants had been inf ated to 360 cc on each side.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient is a tall, asthenic woman who has undergone bilateral augmentation
mammaplasty; she has well-healed, barely visible periareolar scars. The breasts are
slightly asymmetrical, with the le t breast appearing about 25% to 30% smaller in
volume than the right breast. The disparity in breast volume is better seen when her
arms are raised. The patient has an obvious pectus excavatum, best seen in oblique
views, and both her implants appear to be displaced laterally, resulting in exces-
sively wide cleavage. The implants were placed subpectorally, so when she f exes
her pectoral muscles, the breasts are f attened and her implants are displaced later-
ally. A pinch test reveals that the patient has only about 1 cm thick breast paren-
chyma at the superior border o the implant and less than 1 cm so t tissue coverage
along the parasternal border o the breasts, so conversion to the submammary posi-
tion is not an option. The patient is interested in larger implants, in part to make up
or breast atrophy and ptosis that occurred ollowing her pregnancy.
ANALYSIS O F THE PRO BLEM
This patient presented with partial def ation o a saline- lled implant 11 years a ter
primary breast augmentation. She has an underlying pectus excavatum de ormity;
her implants were displaced laterally and she experienced animation de ormity as
a consequence o subpectoral positioning o the implants. The patient was eager to
have her saline implants replaced with silicone gel prostheses. Because the patient is
very thin and the pinch test revealed parenchymal thickness o less than 1 cm along
the parasternal area, we elected to maintain the implants in the subpectoral plane.
The plan was to close the pockets laterally to prevent outward dri t o the implants
and to open them medially to improve cleavage. Because o the pectus de ormity,
it was important to make certain the pockets were not dissected too close to the
midline; patients with pectus excavatum de ormities are prone to synmastia. The
patient requested that her breast volume be increased by at least one cup size and
agreed to have implants o approximately 600 cc. Preoperative measurement o the
width o the hemithorax and determination o parenchymal thickness medially and
laterally dictated that or the volume implant she desired, a moderate plus pro le
device would be the best option to produce her desired breast base diameter.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o both saline implants
Enlargement o the subpectoral pocket medially
Per ormance o lateral capsuloplasties
Insertion o new larger moderate pro le silicone gel implants

Chapter 7 • Deflated Saline Implants
101
TECHNIQ UE
The operation was initiated on the le t side, where the existing periareolar scar was
incised. The wound was deepened through the breast parenchyma and the capsule
was opened. A partially def ated saline implant was removed. The elastomer shell
appeared to be intact, suggesting that the device had leaked through an incompe-
tent ll valve. A medial capsulotomy was per ormed using electrocautery to enlarge
the subpectoral pocket. Care was taken to preserve partial attachment o the ori-
gins o the muscle to the sternum to prevent synmastia. Laterally, a capsuloplasty
was per ormed. The pocket was reduced in dimensions so it did not extend be-
yond the anterior axillary line. The capsuloplasty de ect was closed with a running
continuous locked 0 Prolene suture. A sizer o the desired volume and projection
was inserted and the patient was placed in the sitting position; skin markings were
made in areas where the lateral contour o the breast was blunted or irregular. The
patient was returned to the supine position, the sizer removed, and cautery used to
release the pocket laterally, to achieve the desired smooth contour. A Natrelle Style
20 600 cc silicone gel implant (Allergan, Irvine, CA) was rinsed in Betadine and in-
serted into the subpectoral pocket, and the periareolar incision was closed in layers.
Identical steps were carried out on the contralateral side.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient had an unevent ul postoperative course and achieved a good result.
Postoperative photos obtained at 6 months reveal improved symmetry and a nar-
rower, more aesthetic cleavage. The pectus excavatum de ect is less apparent and
the implants are not displaced as ar laterally, especially on the right side.

Part II: Problems in Augmentation Mammaplasty
102
The lateral contour o the breasts is not per ect; there remains some blunting on the
right side resulting rom the capsuloplasty. Despite the substitution o silicone gel
or saline implants, the patient still has some minor waviness because o her very
thin so t tissue envelope, which is most evident along the lateral border o the le t
breast.
TEACHING PO INTS
Def ation o saline implants is a well-recognized complication o breast augmenta-
tion and is one o the major disadvantages o inf atable prostheses. The incidence
o def ation is much higher with textured saline implants (compared with smooth
devices) and higher in patients with signi cant capsular contracture. Under lling
o inf atable implants also contributes to an increased risk o def ation. Although
trauma may precipitate some def ations, most cases occur sporadically and are
probably caused by old f aw ailure. The diagnosis o a leaking saline implant is
easy to make and is usually rst recognized by the patient hersel . Sometimes im-
plants completely def ate; other times (as in this case) they only partially def ate. I
the problem is not treated early, the scar tissue capsule around the implant o ten
contracts and will need to be released at the time o implant removal and replace-
ment. Treatment o def ated saline implants is straight orward, and o ten (as in this
case) provides the opportunity to address other de ciencies in the patient’s overall
aesthetic result.
BIBLIO GRAPHY
Cunningham BL, Lokeh A, Gutowski KA. Saline- lled breast implant sa ety and e cacy: a multi-
center retrospective review. Plast Reconstr Surg 105:2143-2149, 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, Cordray T, Gutierrez J, et al. A long-term study o outcomes, complications and patient
satis action with breast implants. Plast Reconstr Surg 117:757-767, 2006.
Lantieri LA, Roudot-Thoraval F, Collins DE, et al. Inf uence o under lling on breast implant def a-
tion. Plast Reconstr Surg 100:1740-1744, 1997.
Lavine DM. Saline inf atable prostheses: 14 years’ experience. Aesthetic Plast Surg 17:325-330, 1993.

8a Pocket Exchange—Subglandular to Subpectoral—
With ADM
Ma u r ic e Y. Na h a bed ia n
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
A 55-year-old woman presented to the clinic a ter having undergone bilateral
breast augmentation using silicone gel implants 27 years previously. The speci c
details about her original surgery were unknown and not retrievable, and no revi-
sions, reoperations, or implant exchange procedures were ever per ormed. Her pri-
mary complaint on presentation was bilateral capsular contracture and asymmetry.
C h a p t e r 8
INTRACAPSULAR RUPTURE
AND GEL BLEED
103

Part II: Problems in Augmentation Mammaplasty
104
Both breasts had become rm over the past 10 years, and the le t breast had been
noted to increase in size relative to the right breast over the past year. She had de-
veloped progressive distortion and issues with palpability and pain that extended
rom the chest wall to the NAC. A recent mammogram demonstrated bilateral
capsular contracture without any evidence o a so t tissue mass. Bilateral capsular
calci cation was noted, and intracapsular rupture was suspected. The patient was
healthy with no medical issues. She did not use tobacco products, and was no lon-
ger working.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The breasts are very rm, and classi ed as Baker grade IV capsular contracture.
The amount o so t tissue relative to the implants is small. Based on physical ex-
amination, it is estimated that the implants are responsible or approximately 80%
o the projecting breast volume. The breast skin is thin, and there is no evidence o
erythema, drainage, ecchymosis, discoloration, f uctuance, or wound. Contraction
o the pectoralis major muscle does not result in any degree o animation. It was
speculated that the breast implants were placed in the subglandular space.
ANALYSIS O F THE PRO BLEM
In a patient with longstanding breast augmentation (more than 20 years), progres-
sive capsular contracture is relatively common. Calci cation o the capsule can oc-
cur over time. The speci c reasons or the recent change in the volume o the le t
breast were not obvious on physical examination; however, I suspected that there
had been minor bleeding, most likely as a result o calci c erosion rom the capsule
to the adjacent pectoral muscle. This theory seemed most plausible, given that there
were no abnormal masses noted on breast imaging.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the ruptured gel implants
Total capsulectomy
Pocket site change, placing the new implant in the subpectoral space
Consideration o the use o ADM

Chapter 8 • Intracapsular Rupture and Gel Bleed
105
TECHNIQ UE
The le t in ramammary scar was incised and lengthened to 6 cm. My initial plan
was to dissect around the capsule, which was in the subglandular space, and to re-
move the capsule and implant as a single unit; however, the adherence between the
thin parenchyma and capsule was dense, so I decided to enter directly in the calci-
ed capsule.
The silicone implant was clearly ruptured, showing evidence o brown pigmenta-
tion consistent with old blood. All ree silicone and capsule were removed. The
capsule itsel was heavily calci ed, with sheets o calcium throughout. The capsule
was gently dissected to minimize parenchymal thinning. There was no evidence o
extracapsular silicone gel. The same technique was used on the right breast, where
the only di erence was that there was no evidence o old blood. Both pockets were
copiously irrigated with an antibiotic solution.
The next step was to reposition the new devices. The in erior border o the pectora-
lis major muscle was divided bilaterally, and a subpectoral plane was created. I de-
cided to use ADM to provide tissue support to the lower pole o the breast and to
prevent window-shading o the pectoralis major muscle. High pro le round smooth
400 cc silicone gel implants were used and the neopockets closed with absorbable
mono lament sutures. Drains were placed between the ADM and the breast tissue.

Part II: Problems in Augmentation Mammaplasty
106
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The 1-year ollow-up photographs demonstrate improved contour and symmetry.
The ADM was e ective in controlling the pocket and preventing window-shading.
The breast is so t and supple, demonstrating a natural contour and good symmetry
with no evidence o capsular contracture.
TEACHING PO INTS
Capsular contracture associated with calcif cation o the capsule and intracapsular
rupture requires total capsulectomy, and site change o the implant to a new loca-
tion is almost always necessary. Pocket conversion rom subglandular to subpecto-
ral is acilitated by the use o ADM.
BIBLIO GRAPHY
Nahabedian MY, Patel K. Management o common and uncommon problems a ter breast augmenta-
tion. Clin Plast Surg 36:127-138, 2009.
Nahabedian MY, Spear SL. Acellular dermal matrix or secondary procedures ollowing prosthetic
breast reconstruction. Aesthet Surg J 31(7 Suppl):38S-50S, 2011.
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.

8b Explantation, Capsulectomy, and Conversion
to a Submuscular Pocket
Br ia n d . pet er so n
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 31-year-old nulliparous smoker had undergone previous periareolar subglan-
dular breast augmentation with smooth wall silicone gel implants 4 years earlier.
Three weeks a ter her initial surgery, she developed a right-sided in ection that was
treated conservatively with antibiotic therapy. She then developed a Baker grade IV
capsular contracture o the right breast. She requested correction o the capsular
contracture and an increase in implant size.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
Both implants are in a subglandular position with grade IV capsular contracture on
the right side and grade II on the le t side. The so t tissue coverage is marginal bilat-
erally, and there is palpable rippling o the le t implant. Minor dystopic asymmetry
o the NAC is present, but both the le t and right NACs are in reasonable position.
107

Part II: Problems in Augmentation Mammaplasty
108
ANALYSIS O F THE PRO BLEM
As shown in the preoperative photographs, Baker grade IV capsular contracture is
present on the right breast. The contraction has created a visible round de ormity
o the breast with severe upper pole ullness in comparison to the le t breast.
RECOMMENDED SOLUTION TO THE PROBLEM
Periareolar incisions
Complete capsulectomies
Use o a closed-suction device to assist implant removal and limit gel
contamination
Placement o submuscular smooth wall cohesive gel implants
TECHNIQ UE
The implants were removed with complete capsulectomies in the initial stage o
surgery. It was important to remove the complete capsule, especially to remove it
o the sur ace o the pectoralis muscle, to allow the muscle to accommodate the
submuscular implant. Ideally there should be complete submuscular coverage so
that this plane cannot communicate with the previous subglandular one. Submus-
cular pocket dissection was per ormed, leaving a lateral portion on the pectoralis
and serratus muscle f bers intact or implant support to prevent lateral migration.
The lower ascial attachment o the pectoralis muscle was le t attached to the chest
wall to prevent window-shading o the muscle and to provide increased so t tissue
coverage in the lower pole. Smooth wall cohesive 480 cc gel implants were placed
in the new pocket.
Serratus anterior muscle
sling; lateral border of
muscle not undermined
Pectoralis major
muscle sling

Chapter 8 • Intracapsular Rupture and Gel Bleed
109
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
Thirteen months a ter revision surgery, the
breasts have remained so t (Baker grade I
bilaterally), and their shape and contour
are improved. Visible or palpable rippling
is not present as a result o improved
so t tissue coverage in the submuscular
position.

Part II: Problems in Augmentation Mammaplasty
110
TEACHING PO INTS
Subglandular placement o smooth wall silicone implants results in a higher long-
term rate o capsular contracture. Postoperative in ection will signi cantly increase
this incidence, resulting in the need or secondary surgery. It may be better to re-
move the in ected implant rst and later per orm breast augmentation a ter the in-
ection has been treated and the tissue has been allowed to so ten; this process usu-
ally takes approximately 6 months.
Investigations to diagnose intracapsular implant rupture are o ten misleading, with
a high alse-negative rate; there ore they are rarely worthwhile in cases in which the
patient will be undergoing revision surgery anyway, because the implant and cap-
sule will both be removed.
Once capsular contracture is established, a di erent type o implant should be used
or revision surgery, and pre erably a virgin tissue plane should be used to prevent
recurrence.
Postoperative massage to maintain a pocket that is larger than the implant may
help to prevent capsular contracture, except when textured implants are used.
The use o ADM should be considered in patients with established capsular con-
tracture. Some evidence has been shown in experimental animal models that ADMs
may reduce the rate o recurrent contracture, but this has not yet been established
in well-controlled human trials.
BIBLIO GRAPHY
Adams WP Jr. Capsular contracture: what is it? What causes it? How can it be prevented and man-
aged? Clin Plast Surg 36:119-126, 2009.
Komorowska-Timek E, Oberg KC, Timek TA, et al. The e ect o AlloDerm envelopes on peripros-
thetic capsule ormation with and without radiation. Plast Reconstr Surg 123:807-816, 2009.
Maxwell GP, Birchenough SA, Gabriel A. E cacy o neopectoral pocket in revisionary breast surgery.
Aesthet Surg J 29:379-385, 2009.
Maxwell GP, Gabriel A. Use o the acellular dermal matrix in revisionary aesthetic breast surgery. Aes-
thet Surg J 29:485-493, 2009.
Peters W. Current status o breast implant survival properties and the management o the woman with
silicone gel breast implants. Can J Plast Surg 15:54-67, 2000.
Printzlau A. Removal o per orated silicone implants: how to avoid a sticky operational eld. Plast
Reconstr Surg 112:715, 2003.
Spear SL, Carter ME, Ganz JC. The correction o capsular contracture by conversion to “dual-plane”
positioning: technique and outcomes. Plast Reconstr Surg 118(7 Suppl):103S-113S, 2006.
Spear SL, Murphy DK, Slicton A, Walker PS; Inamed Silicone Breast Implant U.S. Study Group. In-
amed silicone breast implant core study results at 6 years. Plast Reconstr Surg 120(7 Suppl 1):8S-
16S, 2007.

8c Explantation, Capsulectomy, Tissue Expansion,
and Delayed Implant Placement
Br ia n d . pet er so n
PATIENT HISTO RY LEADING TO SPECIFIC BREAST PRO BLEM
This 37-year-old patient underwent bilateral subglandular breast augmentation
with 500 cc gel implants 10 years previously. She developed bilateral Baker grade
IV capsular contracture with probable intracapsular rupture. She has smoked one
pack o cigarettes per day or the past 20 years.
The initial planned procedure was to remove the implants and surrounding cap-
sules. Intracapsular rupture was ound bilaterally. Because o her smoking history
and risk o tissue necrosis, it was decided to allow the so t tissue envelope to so ten
or 6 months be ore placement o dual plane submuscular anatomic tissue expand-
ers, and eventual change to textured anatomic 475 cc ull height/ ull projection im-
plants 10 months later.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
Initial photographs show subglandular implants with severe Baker grade IV cap-
sular contracture. The overlying so t tissue envelope is minimal. The primary con-
cerns are the patient’s smoking history and the potential or tissue necrosis, includ-
ing the NAC.
111

Part II: Problems in Augmentation Mammaplasty
112
ANALYSIS O F THE PRO BLEM
Be ore the 1991 moratorium, silicone gel implants were constructed with a thin
shell and lled with liquid silicone to impart a more natural eel. The ragile nature
o these implants was associated with gel bleed, which compounded the problems
o capsular contracture and rupture.
Calci cation o the capsule is requently seen, especially with subglandular devices.
A smoking history is associated with postoperative complications, especially tissue
necrosis. A conservative approach should be taken in these patients by employing
staged procedures to avoid vascular compromise.
Placing the implant submuscularly provides increased so t tissue coverage or the
implant. When combined with an anatomic-shaped device, submuscular implant
placement may provide excellent aesthetic results in a very thin patient.
RECOMMENDED SOLUTION TO THE PROBLEM
Implant removal with capsulectomy
Insertion o anatomic tissue expanders
De nitive placement o textured anatomic implants
TECHNIQ UE
A ter bilateral capsulectomies and the implants were removed, contracture o the
so t tissue was seen.

Chapter 8 • Intracapsular Rupture and Gel Bleed
113
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The nal photographs show the results 8 months later, with improved breast shape
and no signs o contracture. This case illustrates the problems associated with min-
imal so t tissue coverage in a patient who smokes and who has Baker grade IV
Submuscular
implant
placement
Fascial
extension
Six months was allowed or tissue so tening. Then textured
anatomic tissue expanders were placed in an upper pole
submuscular/lower pole subglandular position. The de-
vices were progressively expanded to 500 cc, and de nitive
475 cc textured anatomic ull height/ ull projection im-
plants were inserted 10 months a ter nal expansion.

Part II: Problems in Augmentation Mammaplasty
114
capsular-contracted subglandular gel implants. Initial implant removal with cap-
sulectomy is risky by itsel ; but in this case, removal o the partially calci ed cap-
sule was necessary. It is prudent to allow tissue revascularization to occur be ore
placement o the submuscular tissue expanders to avoid vascular compromise. The
subsequent placement o anatomic textured cohesive gel implants maintained the
natural breast contour despite minimal overlying so t tissue coverage. The textured
device may also help to prevent secondary capsular contracture.
TEACHING PO INTS
A history o smoking is a red f ag in reconstructive breast surgery, with the poten-
tial or circulatory compromise. Care ully staged procedures may be advisable to
prevent tissue necrosis.
Old implants with intracapsular rupture o ten have calci cation o the surround-
ing so t tissue, especially in a subglandular location. It is imperative to remove this
tissue to gain a pliable so t tissue environment or secondary procedures. It is ben-
e cial to give the tissue time to mature and so ten be ore additional surgery is per-
ormed.
The new implants should be placed in a submuscular position to obtain additional
so t tissue coverage. A staged expansion was required in this patient because o the
contracted so t tissue envelope. Anatomic textured implants provide an excellent
shape with less upper pole ullness and may lessen the subsequent contracture rate
because o their textured sur ace and submuscular placement. However, with ag-
gressively textured devices, late secondary complications such as spontaneous se-
roma ormation and double encapsulation o the implant have been described.
BIBLIO GRAPHY
Adams WP Jr. Capsular contracture: what is it? What causes it? How can it be prevented and man-
aged? Clin Plast Surg 36:119-126, 2009.
Bengston BP, Van Natta BW, Murphy DK, et al; Style 410 U.S. Core Clinical Study Group. Style 410
highly cohesive silicone breast implant core study results at 3 years. Plast Reconstr Surg 120(7
Suppl 1):40S-48S, 2007.
Brown M. Personal communication. RASAPS, April 2009.
Hedén P, Boné B, Murphy DK, et al. Style 410 cohesive silicone breast implants: sa ety and e ective-
ness at 5 to 9 years a ter implantation. Plast Reconstr Surg 118:1281-1287, 2006.
Peters W. Current status o breast implants survival properties and the management o the woman
with silicone gel breast implants. Can J Plast Surg 8:54-67, 2000.
Printzlau A. Removal o per orated silicone implants: how to avoid a sticky operational eld. Plast
Reconstr Surg 112:715, 2003.
Spear SL, Carter ME, Ganz JC. The correction o capsular contracture by conversion to “dual-plane”
positioning: technique and outcomes. Plast Reconstr Surg 118(7 Suppl):103S-113S, 2006.
Spear SL, Murphy DK, Slicton A, Walker PS; Inamed Silicone Breast Implant U.S. Study Group. In-
amed silicone breast implant core study results at 6 years. Plast Reconstr Surg 120(7 Suppl 1):8S-
16S, 2007.

8d Explantation, Capsulectomies, and Conversion
to Subpectoral Pockets
Lo u is L. St r o c k
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 40-year-old woman had undergone breast augmentation approximately
15 years earlier. She presented or revision surgery to address a progressive increase
in breast rmness that she noted over the previous 2 to 3 years. She also wanted to
improve her breast shape and obtain a so t and symmetrical result. She reported
that she had silicone gel implants that were placed on top o the pectoral muscles
and she thought her implant volume was 140 cc. This woman was a healthy non-
smoker with no signi cant medical issues.
ANATOMIC DESCRIPTIO N O F PATIENT’S CURRENT STATUS
This patient has unctional deterioration o her augmented breasts rom severe cap-
sular contractures. She has Baker grade III capsules bilaterally, with severe distor-
tion o breast shape. Her implants are signi cantly displaced superiorly and later-
ally, with bilateral distortion o the IMF level and shape. She has slight breast and
chest asymmetry. Her breast tissue is minimal, with pinch thickness o less than
1 cm. Her NACs are slightly asymmetrical and lateral in location bilaterally. There
is no implant movement noted with pectoral muscle contraction, which is consis-
tent with subglandular implant location.
ANALYSIS O F THE PRO BLEM
Many patients with breast implants will develop an aesthetic deterioration over
many years; in this patient, deterioration had taken the orm o progressive rm-
ness bilaterally. This patient was counseled that this increase in rmness can be
caused by many issues, one o which is implant rupture or leakage o implant ller
material, known as silicone bleed. While MRI evaluation could have determined
whether the implants were intact, we thought that this was not necessary, because
115

Part II: Problems in Augmentation Mammaplasty
116
the treatment or her situation was removal and replacement o her implants, re-
gardless o what the MRI ndings would have been. This patient’s revision proce-
dure was planned to address her suspected implant rupture by creating a new tissue
pocket to both lessen her chance o recurrent contracture and to improve her tis-
sue cover because she had extremely thin tissues. Additionally, the goal was to use
devices that were wide enough to accommodate whatever width device could be
used to lessen the severity o the wide intermammary distance present at the time o
revision.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o previous implants
Total rather than partial capsulectomy, pending intraoperative ndings
Implant replacement with pocket site change rom subglandular to partial sub-
pectoral space
TECHNIQ UE
Her previous in ramammary incision was used or the procedure, with the deep tis-
sue cut beveled superiorly to maintain deep IMF tissue attachments. Dissection was
continued superiorly. The implant capsule was noted to be severely calci ed, with
no evidence o silicone material external to the implant capsule. Because o the se-
vere calci cation visible in the implant capsule, we decided to per orm a complete
capsulectomy. As is commonly the case in patients with capsular contracture with

Chapter 8 • Intracapsular Rupture and Gel Bleed
117
severe calci cation, the contracture process displaces the device so ar superiorly
that the IMF is well below the in erior capsule edge; this allows preservation o this
area despite total capsulectomy. The IMF is protected by signi cant retraction o
the encapsulated implant superiorly, toward the clavicle, especially during dissec-
tion o the in erior portion o the capsulectomy procedure. The ability to maintain
a clear dissection plane and preserve this area allows the removal o the device and
capsule intact without entering the implant capsule. We divided the capsule on the
back table, which revealed signi cant implant gel bleed with severe calci cation.
The pocket was irrigated with hal -strength Betadine, or which o -label consent
was obtained preoperatively, and then rinsed the pocket with saline solution until it
ran clear.
To convert to a partial subpectoral tissue pocket, the pectoralis major was mobi-
lized and tacked to the undersur ace o the overlying breast tissue. Laterally, a lim-
ited cu o the serratus anterior and the pectoralis minor was mobilized and tacked
to the undersur ace and the lateral aspect o the overlying breast tissue. This was
done to create a continuous partial submuscular or dual plane tissue pocket. The
tacking sutures closed o the previous subglandular space. The partial subpectoral
space was irrigated with antibiotic solution and then by local anesthetic solution.
A chest wall measurement was taken, corresponding to the width o a 325 cc high
pro le smooth silicone gel implant. During the preoperative consultation, this pa-
tient agreed to the use o high pro le silicone gel implants, with the speci c width
to be chosen based on intraoperative ndings rom a group o implants selected in
advance.

Part II: Problems in Augmentation Mammaplasty
118
The patient was placed in 45- and 80-degree sitting positions to con rm the over-
all contour, correct implant position, and shape o the IMF. A small closed suction
drain was then placed laterally along the IMF. A multilayer closure was per ormed,
rst in the breast tissue layer, deep dermis, and super cially. She was again placed in
the sitting position to con rm that no distortion o shape or contour had occurred
as a result o the multilayer closure. An identical procedure was per ormed on the
contralateral side. On completion o the procedure, a pressure dressing was placed.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The postoperative photographs at 9 months show that the procedure was success-
ul in improving breast contour and shape as well as tissue cover and so tness. Al-
though there has been a slight in erior movement o the implant position over time,
the patient has had signi cant aesthetic improvement, and is pleased with the out-
come. She has maintained a so t result with no evidence o recurrent capsular con-
tracture. When she was last seen, at 18 months postoperatively, she reported that
she was pleased with her result, but photographs were not taken at that time.

Chapter 8 • Intracapsular Rupture and Gel Bleed
119
TEACHING PO INTS
Total capsulectomy is the treatment o choice in a patient with severe capsular con-
tracture when signi cant capsular calci cation is ound intraoperatively. Although
subtotal capsulectomy can be considered in selected patients, it is not recommended
or patients with calci cation, gel bleed, or gel implant rupture.
The IMF can be preserved, even with total capsulectomy, by retracting the encapsu-
lated implant superiorly a ter initially evaluating the in erior aspect o the implant
capsule.
Site change procedures are the pre erred treatment o capsular contracture. At the
time o breast implant replacement, conversion o a subglandular tissue pocket to
a partial subpectoral or dual plane tissue pocket is acilitated by tacking the pecto-
ralis major muscle to the undersur ace o the breast tissue. A similar approach can
be used in tacking a limited cu o the serratus anterior and the pectoralis minor to
stabilize the lateral extent o the dual plane pocket.
BIBLIO GRAPHY
Spear SL, Carter ME, Ganz JC. The correction o capsular contracture by conversion to “dual plane”
positioning: technique and outcomes. Plast Reconstr Surg 118(7 Suppl):103S-113S, 2006.
Young VL. Guidelines and indications or breast implant capsulectomy. Plast Reconstr Surg 102:884-
891, 1998.

8e Explantation, Capsulectomy, and Conversion
to Submuscular Pocket With Secondary Mastopexy
Br ia n d . pet er so n
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 63-year-old, otherwise healthy patient had undergone bilateral subglandular
breast augmentation with 225 cc smooth wall silicone gel implants 20 years previ-
ously. She subsequently developed Baker grade IV capsular contracture on the right
side and underwent complete capsulectomy and implant replacement on this side in
the same subglandular plane 4 years be ore she presented. She had again developed
a Baker grade IV capsule on the right side as well as persistent Baker grade III on
the le t side. She requested correction o the “hardness and sagging” o her breasts,
without signi cant change in breast size.
120