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

Part II: Problems in Augmentation Mammaplasty
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TECHNIQ UE
Submuscular dissection was per ormed, leaving a lateral portion o the pectoralis
and serratus muscle 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 saline implants were expanded rom 300
to 325 cc bilaterally to compensate or the 140 cc o breast tissue on the right side
and 154 cc on the le t that was removed with the resection mastopexy. The NAC
was elevated rom 25 to 20 cm bilaterally on a superior pedicle.
Submuscular
implant
placement
Fascial
extension
Serratus anterior muscle
sling; lateral border of
muscle not undermined
Pectoralis major
muscle sling
Lower pole
glandular resection

Chapter 8 • Intracapsular Rupture and Gel Bleed
123
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The postoperative photos were taken 10 months a ter revision augmentation and
mastopexy surgery. The implants remain in a good position, with Baker grade I
capsule ormation. There is no recurrent glandular ptosis rom the resection. The
NAC is centralized in a youth ul position. Visible or palpable rippling is not present
because o submuscular placement o the implant and adequate so t tissue padding.

Part II: Problems in Augmentation Mammaplasty
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TEACHING PO INTS
Established capsular contracture with subglandular silicone gel implants requires
changing the plane o implant placement to minimize recurrence o contracture.
Changing the type o the implant may also diminish the rate o recurrent contrac-
ture. Secondary ptosis o the NAC and glandular tissue can be corrected sa ely by
concurrent resection, creating a long-lasting and youth ul appearance to the breast.
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.
Karnes J, Morrison W, Salisbury M, et al. Simultaneous breast augmentation and li t. Aesthetic Plast
Surg 24:148-154, 2000.
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.
Spear SL, Pelletiere CV, Menon N. One-stage augmentation combined with mastopexy: aesthetic re-
sults and patient satis action. Aesthetic Plast Surg 28:259-267, 2004.
Stevens WG, Stoker DA, Freeman ME, et al. Is one-stage breast augmentation with mastopexy sa e
and e ective? A review o 186 primary cases. Aesthet Surg J 26:674-681, 2006.

9a Submuscular Capsulectomies and Implant Exchange
Dav id A. Ca pl in
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 50-year-old woman presented 23 years a ter having a bilateral submuscu-
lar breast augmentation with textured 200 cc silicone gel implants. She had bilat-
eral grade III capsular contractures with mammographic evidence o rupture. Her
health was excellent. She had breast- ed a ter only the rst o our pregnancies. The
patient’s primary concerns were her ruptured implants, the rmness o her breasts,
and their exaggerated round appearance. Progressive capsular contracture o both
breasts was noted over the past 5 years. She reported that the volume o her le t
breast was always slightly larger than that o her right breast. She wanted to in-
crease her breast implant size slightly and pre erred highly cohesive contoured im-
plants i possible. She disliked the round look o her current implants.
125
C h APt e r 9
EXTRACAPSULAR RUPTURE,
GEL MIGRATION, AND SILICONE
INJECTIONS

Part II: Problems in Augmentation Mammaplasty
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ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient’s NAC is 21 cm rom the suprasternal notch (SSN) bilaterally. Her
breast width measures 11.5 cm, her IMFs are 8.5 cm below her nipples, and she has
less than 3 cm o upper pole pinch bilaterally. Her le t breast is larger than her right
breast. She is very thin, 5 eet 4 inches tall, and weighs 111 pounds. She has mature
periareolar scars.
ANALYSIS O F THE PRO BLEM
The patient wanted her ruptured gel implants to be removed and replaced with
highly cohesive contoured implants. Her goal was to have so t breasts with a natu-
ral slope to the upper poles. She was willing to increase her overall volume. Her le t
breast had always been larger than her right breast, and she wanted this corrected
i possible. The periareolar scars were airly short. An in ramammary approach
will acilitate the placement o highly cohesive implants. Because she has agreed
to increase her implant size, a total capsulectomy with precise dissection to tailor
the pocket will be per ormed, allowing contoured, highly cohesive implants to be
placed with minimal risk o rotation.
RECOMMENDED SOLUTION TO THE PROBLEM
Correction through an in ramammary approach
Total submuscular capsulectomies and removal o all ree silicone gel
Selection o appropriate implants using MemoryShape sizers (Mentor, Santa
Barbara, CA) while the patient is in an upright position
Precise dissection o the submuscular pockets to the exact dimensions o the
chosen contoured highly cohesive gel implants
Placement o drains be ore closure
Back f ushing o an antibiotic solution through the drains
Placement o Biopatch dressings (Ethicon, Somerville, NJ) around the drains
TECHNIQ UE
A total capsulectomy was then per ormed on the right breast through an in ramam-
mary approach, and the ruptured gel implant was removed. With the patient in an
erect position, a MemoryShape sizer was used to determine the appropriate implant
size and style. A style MM MemoryShape 280 cc implant (Mentor) was selected. It
had a 12 cm base diameter. The submuscular pocket was care ully tailored to pre-
cisely t the chosen implant.
The procedure was then repeated on the le t side in a similar ashion. A style MM
MemoryShape 245 cc (Mentor) implant with an 11.5 cm base diameter was cho-
sen. This closely approximated her preoperative desired breast width o 11.5 cm.
Drains were placed. The patient’s breasts were covered with Ioban sheeting be ore
the implants were introduced with a no-touch technique. Antibiotic concentrate
was back f ushed through the drains at the completion o the layered closures, and
Biopatch dressings were applied.

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PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
Two years postoperatively the patient has a nice correction o implant malposition
that was caused by capsular contracture. Her breasts have good symmetry with gen-
tly sloping upper poles. Grade I capsules were noted on the long-term ollow-up.
TEACHING PO INTS
The use o highly cohesive contoured implants greatly acilitates revision proce-
dures such as this one by providing a gentle slope to the upper pole o the breast.
As long as the new pocket is care ully tailored to match the dimensions o the im-
plant, the chance o rotation is minimal. The use o contoured sizers is o real ben-
e t or selecting implants o the appropriate size and style.
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.
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.

Part II: Problems in Augmentation Mammaplasty
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Cunningham B. The Mentor Study on Contour Pro le Gel silicone MemoryGel breast implants. Plast
Reconstr Surg 120(7 Suppl 1):33S-39S, 2007.
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.
Hammond DC, Migliori MM, Caplin DA, et al. Memory Contour Pro le Gel implants: clinical out-
comes at 6 years. Plast Reconstr Surg 129:1381-1391, 2012.
Hester TR Jr, Ghazi BH, Moyer HR, et al. Use o dermal matrix to prevent capsular contracture in
aesthetic breast surgery. Plast Reconstr Surg 130(5 Suppl 2):126S-136S, 2012.
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.

9b Multistage Repair With Fat Grafting
An d r e Y. Lev esq u e, Ja mes C. Gr o t t in g
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 61-year-old woman had breast subglandular augmentation mammaplasty us-
ing silicone implants 30 years ago. She presented with an obvious breast de ormity
and desired correction. She complained o marked di erences in the size and shape
o her breasts, which made it di cult to wear bras and some types o clothing. She
had discom ort in her breasts and right axilla. It was evident that her implants had
ruptured, resulting in palpable, extracapsular silicone and rock hard breasts. The
patient had a history o scoliosis.
129

Part II: Problems in Augmentation Mammaplasty
130
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has Baker grade IV contracture o both breasts with palpable masses
in the right axilla. Her nipple position, IMFs, breast size, and breast contour are
asymmetrical. She has minimal breast parenchyma and di use rmness throughout
her breasts. The overlying subcutaneous tissue and skin is thin, providing poor so t
tissue coverage o her breasts. She also has signi cant chest wall asymmetry with
scoliosis o the spine.
ANALYSIS O F THE PRO BLEM
The implants and breast parenchyma with embedded silicone needed to be re-
moved. Because the blood supply o the overlying skin can be compromised during
resection, so t tissue quality can be a ected. In this situation, staging o the compo-
nents o the procedure can reduce potential complications.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the implant material and involved breast tissue
Total capsulectomy
Removal o the axillary silicone in a separate stage
Staged reconstruction o the near-total mastectomy using autologous at gra ting
TECHNIQ UE
In the rst stage, near-total mastectomy was per ormed through her previous IMF
incisions. It was the only way to remove all o the extracapsular silicone. The old
capsule and implant were removed with blunt and cautery dissection, but it was not
sa e to proceed in the axilla because o the presence o embedded silicone around
the axillary vein and brachial plexus. Better exposure was required to sa ely remove
the axillary silicone mass. The area was copiously irrigated and closed over drains.
Migrated silicone can be di cult to isolate and remove with limited exposure.
Counterincisions can be required to treat di use silicone extravasation.
Implant material and capsule from right breast
Implant material and capsule from left breast

Chapter 9 • Extracapsular Rupture, Gel Migration, and Silicone Injections

131
The patient is shown a ter the rst stage. She has a residual siliconoma in her right
axilla.
At the second stage, an incision was made directly over the right axilla to provide
access to remove the implant material siliconoma.

Part II: Problems in Augmentation Mammaplasty
132
The right breast was gra ted with autologous at harvested rom the patient’s lat-
eral thighs. Conventional liposuction was per ormed with a trap to collect the li-
poaspirate. This was then ltered using a strainer and trans erred to 10 ml syringes
or injection.
On the right breast, 80 cc was placed into the medial aspect and 60 cc into the lat-
eral aspect. During injection, inadvertent intravascular injection was prevented
with constant movement o the injection cannula. Fat was deposited in multiple di-
rections and layers in a three-dimensional construct to restore volume and shape.
Collection canister
Lipoaspirate filtered with strainer and irrigated
Excess fluid drained and prepared
for transfer to syringes
Transfer of fat to 60 ml syringes
using a spoon
Transfer of fat to 10 ml syringes
for injection

Chapter 9 • Extracapsular Rupture, Gel Migration, and Silicone Injections

133
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 8 months a ter one session o at gra ting. Her breasts are
so ter and have good symmetry.

Part II: Problems in Augmentation Mammaplasty
134
A second at gra ting procedure is planned or bilateral placement o at to increase
size and improve symmetry.
TEACHING PO INTS
In patients with implant rupture who no longer desire the aesthetic appearance o
implants, conversion to an autologous reconstruction with at gra ting can restore
the breasts. Multiple sessions o at gra ting can be per ormed easily with minimal
downtime. The main constraint is the availability o donor at.
For autologous at trans er, small aliquots o at are placed in multiple planes and
layered in a three-dimensional ashion. An 18-gauge needle with POCAR (Tulip
Medical Products, San Diego, CA) allows access or at injection with no percepti-
ble scarring. Staged procedures reduce potential complications i vascular compro-
mise to overlying skin and so t tissue is likely. Because this patient required essen-
tially partial mastectomies, decreased blood supply was likely at the rst procedure.
Whether at or implants are used or reconstruction, the pressure rom either can
urther compromise blood f ow. Extravasation o silicone into the axilla usually re-
quires a separate incision or proper exposure to prevent injury to the axillary ves-
sels and nerves. It is critical not to exceed the capacity o the recipient site, because
over lling can reduce the viability o trans erred at.
BIBLIO GRAPHY
Bircoll M. Cosmetic breast augmentation utilizing autologous at and liposuction techniques. Plast
Reconstr Surg 79:267-271, 1987.
Hausner RJ, Schoen FJ, Pierson KK. Foreign-body reaction to silicone gel in axillary lymph nodes a -
ter an augmentation mammaplasty. Plast Reconstr Surg 62:381-384, 1978.
Illouz YG, Sterodimas A. Autologous at transplantation to the breast: a personal technique with
25 years o experience. Aesthetic Plast Surg 33:706-715, 2009.

9c Bilateral Mastopexies With Implant Insertion
n ea l h a n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 64-year-old woman had cosmetic breast augmentation in 1970 at the age
o 26. She presented with a 4-year history o a slowly enlarging, rm mass in the
lower outer quadrant o her right breast. Serial mammography con rmed bilateral
silicone implant rupture with extracapsular leakage that was worse on the right
side. She initially was reluctant to undergo surgery, but eventually decided to have
the silicone removed. She wanted her breasts to be the same size and upli ted.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient is slightly overweight. The in ramammary scars rom her original sur-
gery are well healed. Her breasts are large and pendulous with signi cant descent
o the NACs. (The sternal notch-to-nipple distance is 30 cm.) Multiple, rm sili-
cone granulomas are palpable bilaterally and are much more severe on her right
side. The lower outer quadrant o her right breast is almost entirely replaced by an
irregularly shaped rm mass. The skin over this area is characterized by plaquelike
thickening secondary to silicone in ltration o the dermis.
135

Part II: Problems in Augmentation Mammaplasty
136
ANALYSIS O F THE PRO BLEM
The patient was a candidate or removal o the ruptured implants, the ree sili-
cone, and as many areas o silicone mastitis, granulomas, and silicone dermatitis
as reasonably possible. Because most o the extravasated silicone was con ned to
the lower outer quadrant o her right breast, a conventional Wise mastopexy was
a good option, incorporating resection o silicone-in ltrated tissues. She wanted
her breasts to be approximately the same size postoperatively; there ore new im-
plants needed to be inserted. Implants o di erent sizes and shapes were probably
needed, because more tissue had to be resected rom her right breast. The patient
was in ormed o the risk o ischemia o her NACs and skin f aps. The possible need
to stage the procedure, depending on ndings at the time o surgery, was discussed.
In this case, the rst stage would consist o removal o leaking silicone and masto-
pexy; new implants would be inserted at a second stage.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o ruptured implant and all ree silicone gel
Removal o silicone mastitis, granuloma ormation, and silicone dermatitis areas
Bilateral Wise-pattern mastopexy
Insertion o new silicone gel implants o two di erent sizes and pro les
TECHNIQ UE
Preoperatively markings were made or a bilateral Wise-pattern reduction mam-
maplasty. The standard marking o the in erior pedicles was modi ed to allow re-
section o all areas o silicone-in ltrated dermis o the lower outer quadrant o the
right breast. An intact dermal in erior pedicle was preserved. The area o proposed
skin resection is indicated by cross-hatching.

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The vertical pedicle was deepithelialized, creating a superior and in erior pedicle
to the NACs. The primary blood supply to the NACs was via the superior pedicle;
however, the purpose o retaining a viable in erior pedicle on both sides was to re-
in orce the T junction o the mastopexy f aps in the event o wound breakdown.
The ruptured implant and capsule on the le t side was removed. It weighed 339 g.
With the in erior pedicle serving as a barrier to prevent implant exposure in the
event o a wound breakdown, a smooth 325 cc Moderate Plus Pro le gel- lled im-
plant (Mentor, Santa Barbara, CA) was inserted in the le t breast.

Part II: Problems in Augmentation Mammaplasty
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A custom-designed pedicle (marked as a stippled area) was created on the patient’s
right breast to preserve a superior and in erior f ap. This would allow ull- thickness
resection o silicone mastitis and dermatitis in the lower outer quadrant (area
marked on the breast with cross-hatching). Full-thickness skin, along with under-
lying areas o silicone-in ltrated parenchyma, was resected in continuity with the
capsule and ruptured implant to minimize leakage o ree gel into the operative
wound.
The completely resected specimen weighed 595 g. The in erior portion o the verti-
cal pedicle was repositioned to the midline o the breast, to rein orce the T junction
in the event o wound breakdown.

Chapter 9 • Extracapsular Rupture, Gel Migration, and Silicone Injections

139
The right breast was reconstructed with a 550 cc High Pro le silicone gel implant
(Mentor).
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient has a good result 6 months postoperatively. She has virtually complete
removal o all ree silicone, and all areas o silicone mastitis, granuloma ormation,
and dermatitis. Reconstruction with two di erent-sized and di erent-shaped im-
plants has restored the desired breast volume and maintained symmetry; bilateral
mastopexy helped achieve the desired breast contour.

Part II: Problems in Augmentation Mammaplasty
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By customizing the approach to meet the patient’s needs, it was possible to sa ely
achieve her aesthetic goals.
TEACHING PO INTS
In patients with silicone implant rupture and extracapsular leakage, gel can invade
the breast parenchyma, the underlying muscles and ascia, and the skin. It is ideal
to remove as much o the involved tissue as practical, but at times residual silicone
deposits will remain in the tissue. This does not increase the risk o subsequent neo-
plasm or o any systemic illness. Treatment needs to be individualized or each pa-
tient. In patients who have a secondary mastopexy and reinsertion o implants (as
in this case), a viable layer o tissue is needed beneath the junction o the skin f aps
to ensure that the implant will not become exposed i wound breakdown occurs.
BIBLIO GRAPHY
Ahn CY, Shaw WW. Regional silicone-gel migration in patients with ruptured implants. Ann Plast
Surg 33:201-208, 1994.
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.
Hölmich LR, Friis S, Fryzek JP, et al. Incidence o silicone breast implant rupture. Arch Surg 138:801-
806, 2003.
Hölmich LR, Vejborg IM, Conrad C, et al. Untreated silicone breast implant rupture. Plast Reconstr
Surg 114:204-214, 2004.

9d Silicone Injection Correction With Bilateral
Mastectomies With TRAM Flaps
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 52-year-old woman had direct silicone injections 25 years ago, while she was
living in Asia. Nonmedical grade silicone was placed in both breasts. During the
past several years, she has had recurrent problems with siliconomas, which required
multiple excisions o recurrent abscesses. At presentation, both breasts were lled
with multiple nodules associated with the dispersion o silicone throughout each
entire breast. The patient was otherwise in good health and a nonsmoker. She was
not aware o any history o breast cancer in her amily.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has relatively small, symmetrical, nonptotic breasts. Each NAC is 5 cm
above the IMF. On palpation numerous rm nodules are identi ed throughout the
entire breast mound bilaterally. Some o these nodules are near the sur ace, whereas
others are deep within the breast tissue itsel . She has no open sores rom any o her
previous abscesses, although small punctate scars are present on the skin sur ace.
ANALYSIS O F THE PRO BLEM
The only solution or this patient was bilateral nipple-sparing mastectomies and
reconstruction with implants or autologous tissue. Because o her history o multi-
ple abscesses, implants had a signi cant potential or in ection, whereas autologous
tissue was more likely to tolerate this chronically in ected space and bring a new
blood supply to this severely traumatized tissue. Mastopexy was not required, be-
cause the patient had relatively small, nonptotic breasts.
141

Part II: Problems in Augmentation Mammaplasty
142
RECOMMENDED SOLUTION TO THE PROBLEM
Bilateral nipple-sparing mastectomies through IMF incisions
Bilateral deepithelialized transverse rectus abdominis myocutaneous (TRAM)
f aps with small transverse skin islands placed along the IMFs
TECHNIQ UE
Seven-centimeter incisions were made on each side along the patient’s IMFs. Us-
ing scissor dissection, a plane was created between the overlying skin and subcu-
taneous tissue and underlying breast tissue. A normal plane was not identi ed, as
in most mastectomy patients, because o the distortion rom silicone injections and
the recurrent abscesses. Using a lighted retractor, this plane was completed, and a
posterior dissection was per ormed, with elevation o the breast o the underlying
musculature. Both silicone-embedded breasts were delivered through the in ramam-
mary incisions. Bilateral TRAM f aps were raised using a muscle-sparing technique.
Vertical elliptical skin islands were created on the f aps to be later rotated 90 de-
grees or creation o the IMF area. The rest o the f aps were deepithelialized in situ
be ore trans er. Next, tunnels were created or placement o the bilateral TRAM
f aps into the space created by the mastectomies. The pockets were irrigated with
antibiotic solution, and hemostasis was con rmed. The TRAM f aps were sutured
into place over drains.
Muscle and deepithelialized
tissue add depth to parenchyma
Skin flap creates lower pole
Flap tunnels under skin
Nipple-sparing mastectomy
Muscle-sparing TRAM flap raised
TRAM flap in place

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143
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 3 years postoperatively with a healed abdomen and excellent
restoration o her breast contour and shape. Small skin islands rom the TRAM
f aps were le t in the original transverse in ramammary incisions. She has had no
urther episodes o in ection and continues to do well. Although implants were an
option in this patient and would have required less surgery, they might have caused
more long-term problems because o her history o in ection. One bene t o using
autologous tissue is that it better tolerates scarred, in ected, and irradiated spaces.

Part II: Problems in Augmentation Mammaplasty
144
TEACHING PO INTS
In patients who have had nonmedical silicone injection throughout their breasts,
simple or nipple-sparing mastectomies can be a good solution. Because this patient
had recurrent abscesses over many years, any treatment short o removal o her
breasts was unlikely to solve the problem. The use o autologous tissue to supply
a new source o blood, whether by pedicle or ree f ap, has the highest probability
o success.
BIBLIO GRAPHY
Chiu WK, Lee TP, Chen SY, et al. Bilateral breast reconstruction with a pedicled transverse rectus ab-
dominis myocutaneous f ap a ter subcutaneous mastectomy or symptomatic injected breasts.
J Plast Surg Hand Surg 46:242-247, 2012.
Echo A, Otake LR, Mehrara BJ, et al. Surgical management o silicone mastitis: case series and review
o the literature. Aesthetic Plast Surg 37:738-745, 2013.
Sahin I, Isik S, Alhan D, et al. One-staged silicone implant breast reconstruction ollowing bilateral
nipple-sparing prophylactic mastectomy in patients at high-risk or breast cancer. Aesthetic Plast
Surg 37:303-311, 2013.
Sánchez-Ponte A, Martí E, Rubio J, et al. Illegal injection o industrial silicone oil or breast augmenta-
tion: risks, solutions and results. Breast J 18:174-176, 2012.
Vanwambeke K, Wittevronghel I, Dekeyzer S, et al. Breast augmentation by injection o ree silicone:
MRI ndings. JBR-BTR 95:34, 2012.

10a Removal of Shaped Implants, Pocket Conversion,
Mastopexy, and Insertion of Round Implants
Nea l Ha n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 38-year-old Russian woman presented with breast asymmetry and de ormity
a ter previous breast implant surgery.
145
c H a Pt e r 10
IMPLANT ROTATION WITH
SHAPED IMPLANTS

Part II: Problems in Augmentation Mammaplasty
146
The patient was a healthy woman with three children, all o whom she breast- ed.
Approximately 6 years ago, she underwent breast augmentation in Moscow. Two
years later, because o persistent ptosis, she underwent a revision, including inser-
tion o new implants and a periareolar mastopexy. Operative reports rom the two
preceding procedures were not available. The patient stated that she had 320 cc
anatomic shaped implants but was uncertain whether they were placed above or
below the pectoral muscle. Her primary concerns were that her breasts were asym-
metrical, and she considered her le t breast de ormed. She was also unhappy with
her scars, which she thought were too conspicuous.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient is a tall, slender woman who previously underwent bilateral augmenta-
tion mammaplasties and bilateral circumareolar (Benelli) mastopexies.
Her breasts are grossly asymmetrical. The right breast has an attractive postaug-
mentation con guration, but the le t breast is distorted, with loss o ullness in the
parasternal region, a vertically oriented projecting ridge along the medial third o
the breast, and f attening o the lateral two thirds o the breast. The IMFs are sym-
metrical, but the in erior pole o the le t breast appears lower than the right side
(pseudoptotic).
There are well-healed circumareolar scars bilaterally; however, the scars are con-
spicuous because they are depigmented and all within the darker areolar skin. The
right areola is circular, and the le t areola is oblique. The breasts are so t bilater-
ally (Baker grade I). When the patient f exes her pectoral muscles, there is f attening
o the right breast, indicating that the right implant was placed submuscularly, but
there is no change in the con guration o the le t breast, suggesting that the le t im-
plant is in a submammary pocket. The patient was re erred or mammography. The
radiologist identi ed “bilateral silicone implants; the implant is subpectoral on the
right side, whereas it is subglandular on the le t.” No other signi cant abnormali-
ties were identi ed.
ANALYSIS O F THE PRO BLEM
This patient had rotation o an anatomic or teardrop-shaped le t breast implant.
The device appeared to have rotated 90 degrees clockwise, so the most projecting
part o the breast was in eromedial and the f attest part was superolateral. In ad-
dition to a misshapen breast, the patient had excessively visible scars around her
areolae. The circumareolar scars were conspicuous because they ell within the pig-
mented areolar skin instead o at the pigmented-nonpigmented junction. The le t
areola was distorted, with an eccentric or oblique con guration compared with
the round shape o the right areola. Her cleavage was excessively wide, because the
rotated le t breast implant did not ll out the skin envelope along the parasternal
area.

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RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the anatomic (teardrop-shaped) implants
Modi cation o the submammary pocket on the le t side to properly accommo-
date a round implant
Conversion o the right implant rom the subpectoral to the submammary plane
Insertion o new smooth round silicone gel implants
Bilateral revision o the circumareolar mastopexy
TECHNIQ UE
The operation was begun on the le t side. Circular templates o two di erent diam-
eters were used to draw concentric circles centered on the nipple; the outer circle
was drawn large enough to ully encompass the residual pigmented areolar skin ly-
ing outside the existing scar. The area between the circles was deepithelialized and
the wound was deepened in eriorly until the scar tissue capsule around the implant
was ound. The anterior capsule was incised and the implant removed. The im-
plant was textured and teardrop shaped and had rotated clockwise. The implant
was in the submammary plane, but a separate subpectoral pocket was identi ed,
indicating that previously an implant had been placed in the submuscular position.
The pectoral muscle was sutured to the underlying chest wall with a series o inter-
rupted gure-o -eight 2-0 Prolene sutures. A medial capsulotomy was per ormed to
open the pocket and create the desired medial breast contour; this maneuver also
helped to narrow the cleavage. Laterally the pocket extended beyond the anterior
axillary line, so a capsulorrhaphy was per ormed, excising the excessive lateral scar
tissue capsule and closing the de ect with a running, locked 0 Prolene suture. Sizers
were inserted into the submammary pocket to determine the exact size o implant
or augmentation. We elected to use a 450 cc smooth round moderate plus pro le
gel implant. The implant was rinsed in povidone-iodine (Betadine) and inserted into
the pocket, and the wound was closed in layers. (The use o Betadine with implants
is currently “o label” but widely considered sa e and may reduce the risk o sub-
clinical in ection and bacterial bio lm ormation, which are hypothetical causes o
capsular contracture.) A periareolar purse-string suture o 2-0 Prolene was placed
using the round block technique to close the outer circular incision and obtain the
desired areolar diameter (4.0 cm). The nal closure o the circumareolar incision
was done in layers, with buried interrupted 4-0 PDS sutures in the deep dermis and
a running subcuticular 4-0 Monocryl suture in the skin.
On the right side, essentially identical steps were carried out. The implant on the
right side was in the subpectoral plane, so the pectoral muscle was reed rom its
attachments to the overlying breast parenchyma to create a submammary pocket
o adequate dimensions. The pectoral muscle was sutured to the underlying chest
wall with a series o interrupted gure-o -eight 2-0 Prolene sutures. An identical
450 cc smooth round moderate plus pro le gel implant was rinsed in Betadine and
inserted into the submammary pocket. A nonabsorbable purse-string suture was
placed, and the deep layers and the NAC were closed in the same manner as on the
contralateral side.

Part II: Problems in Augmentation Mammaplasty
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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.
The improved breast symmetry is seen 3 months postoperatively in rontal, lateral,
and oblique views. The de ormity o the le t breast contour caused by rotation o
the shaped implant has been completely corrected, cleavage has been improved, her
IMFs are symmetrical, the NACs are both circular, and the nipples have been better
centralized within the areolae. The le t areola is slightly larger in diameter than the
right areola; this symmetry could be improved by a revision to reduce the diameter
o the le t areola. The circumareolar scars are much less conspicuous, because they
are now at the junction o pigmented and nonpigmented skin.

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TEACHING PO INTS
Signi cant rotation o a shaped implant usually results in obvious breast de ormity
and asymmetry. Typically, it is easy to determine the direction o rotation by ob-
serving the resulting breast contour. Correction o the de ormity is relatively simple
in a case such as this one, because the patient was a satis actory candidate or re-
placement o her shaped implants with round implants. It was only necessary that
relatively symmetrical pockets be created or placement o the new prostheses. I a
patient with a rotational de ormity is going to have the same (or another) shaped
device inserted, it is imperative that the pocket be reduced to the exact dimensions
o the implant to prevent recurrent rotation. It is also advisable that partial capsu-
lectomy or at least roughening o the capsule sur ace be done to promote adherence
o the textured implant shell to adjacent tissues, thereby urther diminishing the
risk o recurrent rotation. Another option is to create a “virgin” pocket o the cor-
rect dimensions to accommodate the implant. This can be achieved by converting a
submammary implant to the subpectoral plane, or a subpectoral implant to a sub-
mammary or neosubpectoral pocket.
The incidental nding o implants in di erent planes (in this case, le t implant sub-
mammary and right implant subpectoral) is not uncommon in patients who have
had multiple previous operations. It is most likely that this patient’s implants were
placed in the submammary plane during the original breast augmentation but were
converted to the subpectoral position in the revision procedure. However, the po-
tential submammary space on the le t side was not securely closed; at some point,
the implant “herniated” into the old submammary pocket. This did not occur in the
immediate postoperative period, because there was a mature scar tissue capsule lin-
ing the undersur ace o the pectoral muscle on the le t side. It is likely that the her-
niation o the implant back into the old submammary pocket may have contributed
to the subsequent rotation o the device, because the pocket dimensions were prob-
ably larger than the ootprint o the implant.
The undesirable visibility o the circumareolar scars points out the importance o
encompassing all pigmented skin when a circumareolar skin excision is per ormed.
I there is residual pigmented skin beyond the circum erence o the outer incision,
the scar will all inside the periphery o the areola and will almost always be too
conspicuous.
BIBLIO GRAPHY
Baeke JL. Breast de ormity caused by anatomical or teardrop implant rotation. Plast Reconstr Surg
109:2555-2564, 2002.
Benelli L. A new periareolar mammaplasty: the “round block” technique. Aesthetic Plast Surg 14:93-
100, 1990.
Elliott LF. Circumareolar mastopexy with augmentation. Clin Plast Surg 29:337-347, 2002.
Panettiere P, Marchetti L, Accorsi D. Rotation o anatomic prostheses: a possible cause o breast de-
ormity. Aesthetic Plast Surg 28:348-353, 2004.
Spear SL, Giese SY, Ducic I. Concentric mastopexy revisited. Plast Reconstr Surg 107:1294-1299,
2001.

10b Correction of Anatomic Implant Rotation
With Manual Manipulation
Fr a n k List a , Ja mil a h ma d
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 46-year-old woman underwent subglandular breast augmentation through an
in ramammary incision with textured, anatomically shaped, cohesive silicone im-
plants (Allergan Style 410MX, 445 cc). Postoperatively, she did well initially and
was happy with the result. She presented 51⁄2 years later a ter noticing an acute
change in the appearance o her right breast the night be ore. In particular, she elt
that the shape o her right breast was di erent. She had no history o recent trauma
and had not experienced anything similar in the past. Otherwise, she elt well, did
not have any pain, and was a ebrile. She was a healthy nonsmoker with no signi -
cant medical issues.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
This patient has breast asymmetry; the superior pole o the right breast has a f at
appearance. Most o the volume rom the implant remains in the in erior pole o
the breast. The superior borders o the implant eel more well de ned and the su-
perior pole eels f at, because the implant has rotated so that its posterior sur ace is
now anterior, but its upright orientation has been maintained.
150

Chapter 10 • Implant Rotation With Shaped Implants

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ANALYSIS O F THE PRO BLEM
Malrotation is de ned as rotation o an anatomically shaped implant around one
or more axes that changes the implant orientation that was chosen at the time o
surgery. In a recent study reviewing our experience using the Allergan Style 410 im-
plant or subglandular breast augmentation through an in ramammary incision, we
reported that malrotation occurred in 5.2% o patients. When malrotation occurs,
the patient typically notices this immediately and in some cases will manually re-
position the implant be ore presenting or evaluation. O 23 patients with malrota-
tion, our ultimately required reoperation.
Our initial management involves manually repositioning the implant. Then the pa-
tient must wear a tight- tting bra or 6 weeks. Reoperation may be indicated i the
malrotation recurs.
RECOMMENDED SOLUTION TO THE PROBLEM
Manual repositioning o the right breast implant
Have the patient wear a tight- tting bra or 6 weeks a ter manual repositioning
TECHNIQ UE
It is important to understand the orientation o the implant a ter malrotation. We
have observed that the Style 410 implant most commonly rotates rom back to
ront around its vertical axis. The breast volume is still maintained in the in erior
pole, but the superior pole takes on a very f at appearance because o the relatively
f at posterior sur ace o the Style 410 implant.

Part II: Problems in Augmentation Mammaplasty
152
Manual repositioning o the implant is quite straight orward, and this maneuver
should not cause much discom ort or pain. Both hands are used to attempt to ro-
tate the implant around its vertical access so that the ront o the implant that is
against the posterior sur ace o the pocket is rotated 180 degrees to the anterior
sur ace o the pocket, restoring the correct orientation o the implant.
The patient is shown immediately a ter manual repositioning o the anatomically
shaped implant. The appearance o the breast is consistent with its appearance be-
ore malrotation. There is some erythema o the breast as a result o the manipula-
tion; this will resolve. The patient should not have any persistent discom ort or any
appreciable swelling. She must wear a tight- tting bra or 6 weeks a ter manual
repositioning to encourage readherence o the capsule to the implant sur ace. I the
patient reports any speci c activity that caused the malrotation, that activity should
also be avoided or 6 weeks.
Pos te rior
An te rio r
Implant manually
rotated around vertical
axis to correct position
P o s te rio r
Shaped implant,
properly positioned
Ante rior
Change in breast
shape with implant
rotation

Chapter 10 • Implant Rotation With Shaped Implants

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PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 4 months a ter manual repositioning o the right breast im-
plant. Repositioning corrected the breast de ormity and restored the appearance o
the breast to what it was be ore malrotation.
In this case, a relatively simple nonsurgical correction o the problem was achieved
through manual repositioning. In a minority o cases, recurrent malrotation or de-
velopment o other complications, including capsular contracture or late peripros-
thetic f uid collection, may necessitate surgery.
TEACHING PO INTS
Initial correction o a malrotated anatomically shaped implant should be per ormed
by manual repositioning. I the patient develops recurrent malrotation, surgery may
be required.
BIBLIO GRAPHY
Adams WP Jr, Mallucci P. Breast augmentation. Plast Reconstr Surg 130:598e-612e, 2012.
Lista F, Ahmad J. Evidence-based medicine: augmentation mammaplasty. Plast Reconstr Surg
132:1684-1696, 2013.
Lista F, Tutino R, Khan A, Ahmad J. Subglandular breast augmentation with textured, anatomic, co-
hesive silicone implants: a review o 440 consecutive patients. Plast Reconstr Surg 132:295-303,
2013.
Schots JM, Fechner MR, Hoogbergen MM, et al. Malrotation o the McGhan Style 510 prosthesis.
Plast Reconstr Surg 126:261-265, 2010.

10c Shaped Implant Rotation
el iz a bet h J. Ha l l -Fin d l ay
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 35-year-old patient underwent a bilateral subglandular breast augmentation
using Biocell textured cohesive silicone gel breast implants Style 410MF (Allergan).
The implants were 640 cc each. She was 6 eet tall and weighed 250 pounds.
5 months postoperatively
Preoperative
154

Chapter 10 • Implant Rotation With Shaped Implants

155
The patient did well or 17 months and then presented with swelling in the le t
breast. There was nothing to suggest an in ection, so we decided on a conservative
wait-and-see approach. The le t breast continued swelling, so she was taken back to
the operating room, because we assumed that there must be an in ection and that
the implant should be removed.
Instead, there was a complete double capsule with a bloody seroma. There was no
evidence o in ection. Both capsules were completely removed and sent or patho-
logic evaluation. At that time, we were not allowed to have implants in stock in
Canada; there ore the shaped implant was placed back into the pocket.
17 months postoperatively
19 months postoperatively
Capsule removed from breast
Capsule removed from implant
Capsule attached to implant surface
Double capsule before implant removal

Part II: Problems in Augmentation Mammaplasty
156
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient is shown 2 months a ter her revision surgery, with some persistent
swelling but de nite improvement. Four years later she developed capsular contrac-
ture on the right side. She was taken back to the operating room; the plan was to
replace both implants this time. There was only a single capsule on the right side,
with nothing unusual detected. The implant on the le t side that had been returned
to the pocket was not only rotated, with the 6 o’clock position o the implant at
8 o’clock, but also the implant was f ipped back to ront. There was no adherence
o the implant to the breast tissue.
ANALYSIS O F THE PRO BLEM
Because the Style 410 implant was placed back into an overly large pocket, it was
assumed that the implant would not adhere. It had not adhered properly rom the
rst surgery and with removal o both capsules, it was clear that the pocket would
not t snugly around the implant. Although in retrospect one could imagine that
the implant was rotated with the 6 o’clock position o the implant sitting at the
8 o’clock position, it was a surprise that the implant was f ipped back to ront. This
is an example that disproves the claim that the shaped implant gives an improved
shape to the breast.
RECOMMENDED SOLUTION TO THE PROBLEM
Because a shaped implant relies on tissue adherence to prevent rotation, the ollow-
ing measures are appropriate:
Creation o a tight pocket to hold the implant in position to allow adher-
ence, thus preventing rotation.
When a shaped implant must be removed and the pocket is too large to ex-
pect that any adherence will develop, the surgeon should consider placing a
round implant.
2 months after capsule removal and reinsertion of original implants

Chapter 10 • Implant Rotation With Shaped Implants

157
TECHNIQ UE
Initially it was important to create a tight, precisely shaped pocket or a textured
shaped implant to help prevent rotation. Only aggressively textured implants will
adhere, and the implant needs to be held in position or the adherence to occur.
At the time o exploration o the late seroma, it was assumed that neither the origi-
nal nor a new implant would be inserted because we thought that there was likely
an in ection. Instead there was a bloody seroma with a double capsule around the
implant. The gram stain was negative, prompting a di erent decision to be made.
Ideally, a new implant would be used, but this was not possible because all implants
had to be preordered or that speci c patient. Because both the outer and inner
capsules were removed, the pocket was large and the tissue riability prevented clo-
sure to make the pocket precisely t the implant. The patient did well or several
years, proving that there was no in ection, but the implant did not adhere. Because
the pocket was large, the implant was allowed to rotate reely.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
She is shown 19 months a ter the initial shaped implant insertion with the subse-
quent late seroma. In the second set o photos, she is seen 2 months a ter the double
capsule removal and reinsertion o the shaped implant back into the le t breast. The
third set o photos show her at 31⁄2 years a ter the revision when her only concern
19 months postoperatively
2 months after double capsule
removal and reinsertion
of the original shaped implants
31⁄2 years after insertion of
the shaped implants

Part II: Problems in Augmentation Mammaplasty
158
was a right capsular contracture. The le t breast was so t and there was no clinical
evidence o malrotation. The right capsule was released, and both shaped implants
were replaced with smooth round silicone gel breast implants (not shown). The
le t implant in the third set o photos was both rotated and f ipped back to ront,
which is di cult to detect clinically; she had enough padding (breast tissue and at)
to camouf age the shape. This le t implant malrotation cannot be seen in either the
rontal or lateral views. She has since done well with the round implants.
TEACHING PO INTS
Shaped implants need to be held in position to prevent rotation. The pocket can be
created to hold the shape in less aggressively textured implants that will not adhere.
More aggressively textured implants are designed to adhere to the breast tissue, and
this adherence should prevent rotation. In patients with enough tissue or padding,
the shaped implant may rotate, and this may not be obvious. When a shaped implant
is removed rom the original pocket, it should perhaps be replaced with a larger im-
plant or a round implant, because the larger pocket will allow implant displacement.
This case shows that the malrotation was not evident preoperatively, probably be-
cause the patient had enough padding (breast tissue and at) to obscure the implant
shape. I malrotation had been possible, it would probably have been a better choice
to replace the implant with a smooth one where rotation would be less likely. On the
other hand, the implant shape did not matter and the problem with this patient oc-
curred with the development o a double capsule and late seroma. This was neither
in ection nor anaplastic large cell lymphoma (ALCL) and was likely caused by sepa-
ration o the capsule rom the implant, probably rom external shear orce. The two
rough sur aces resulted in development o a bloody seroma.
BIBLIO GRAPHY
Collis N, Coleman D, Foo IT, Sharpe DT. 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.
Daw JL, Lewis VL, Smith JW. Chronic expanding hematoma within a periprosthetic breast capsule.
Plast Reconstr Surg 97:1469-1472, 1996.
Hall-Findlay EJ. Breast implant complication review double capsules and late seromas. Plast Reconstr
Surg 127:56-66, 2011.
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. Late recurrent capsular hematoma a ter augmentation mammaplasty:
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, Tymo i O. Seroma as a late complication a ter breast augmentation. Aesthetic Plast Surg
35:303-314, 2011.
Schiavon M, Fraccalanza E, Baraziol R. Late recurrent capsular hematoma a ter augmentation mam-
maplasty: case report. Aesthetic Plast Surg 29:10, 2005.
Tebbetts JB. Diagnosis and management o seroma ollowing breast augmentation an update. Plast
Reconstr Surg 128:17-25, 2011.

11a Reconstruction With an Expander and a Latissimus
Dorsi Flap
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 39-year-old woman reported an area o raised red so t tissue and skin in her
right IMF that had been present or approximately 2 years. She had had an aug-
mentation 12 years earlier and was told that the so t tissue abnormality in her right
IMF was nothing signi cant. A biopsy was per ormed, which showed dermato -
brosarcoma. She was a healthy individual, a nonsmoker, had no other abnormali-
ties, and had only had the one previous augmentation in the past.
C h a p t e r 11
SPECIAL PROBLEMS: MALIGNANCY
AFTER AUGMENTATION
159

Part II: Problems in Augmentation Mammaplasty
160
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
Her implant type and size are unknown. On physical examination, her breasts are
airly symmetrical. The uninvolved breast is slightly more ptotic. The dermato bro-
sarcoma involves the lower pole o the breast, the IMF, and a portion o the upper
abdominal so t tissue. The NAC and remaining portion o the breast do not require
resection, because a dermato brosarcoma is not breast cancer, although it may in-
volve the lower portion o the so t tissues o the breast.
ANALYSIS O F THE PRO BLEM
Adequate resection o the so t tissue tumor requires removal o the lower pole o
the breast, including the skin and underlying breast tissue. The entire IMF area, as
well as a segment o the upper abdominal skin just below the old, also require re-
section. Patients with dermato brosarcoma have the best chance o cure with an
aggressive resection at the rst procedure.
RECOMMENDED SOLUTION TO THE PROBLEM
Complete resection o the lower pole o breast, including the skin and underly-
ing ascia, as well as the skin o the IMF and upper abdomen
Elevation o a latissimus dorsi myocutaneous f ap
Superior advancement o abdominal skin with xation to the rib periosteum
Use o an adjustable implant to create volume symmetry
TECHNIQ UE
Since the dermato brosarcoma had been present or some considerable time, it
was thought that the skin and the underlying breast tissue o the lower pole o the
breast, as well as the entire IMF area down to the ascia, would require resection.
Although there are several options or recreating the IMF and the lower pole o the
breast, the best is the latissimus dorsi f ap, because this creates a sling that will al-
low re-creation and stabilization o the new IMF.

Chapter 11 • Special Problems: Malignancy After Augmentation

161
The patient also needs advancement o the abdominal wall skin superiorly with
xation using permanent sutures to the rib periosteum. The latissimus dorsi skin
island was placed eccentrically on the patient’s back, so that when it was rotated
anteriorly, the bulk o the muscle would sit superior to the skin island, allowing the
skin island to orm an IMF. Although other f aps, such as the TRAM and others,
could be used to re-create the IMF, they tend to cause in erior displacement o the
old over time, whereas the latissimus dorsi, because o its attachment superiorly,
creates a stable sling or the reconstruction and creation o a new old.
Another issue is creation o symmetry. The f ap will add volume to the recon-
structed breast and it is di cult at the time o the procedure to select the correct
implant size. Also, because o muscle atrophy o the latissimus dorsi over several
months, a static implant may have adequate volume initially but be inadequate at a
later date. Adjustable implants that can be lled over time improve the chances o
symmetry without the need or repeat implant replacement.

Part II: Problems in Augmentation Mammaplasty
162
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
Postoperatively, the new IMF was stable and close to the level o the patient’s con-
tralateral old. On lateral view with the arm elevated, the latissimus dorsi skin is-
land is visible, but with the patient’s arm at her side on the oblique view, the recon-
struction is hidden under the lower pole o the breast. Both the lower edge o the
latissimus dorsi skin island and the superiorly advanced margin o the abdominal
skin were sutured to the rib periosteum with permanent sutures or long-term sta-
bility. The use o an adjustable implant increased the chance o creating symmetry.
The lling valve was le t in or several months postoperatively, acilitating adjust-
ments o volume as swelling subsided and compensating or some volume loss as
the latissimus dorsi muscle atrophied.

Chapter 11 • Special Problems: Malignancy After Augmentation

163
Both volume and old symmetry were success ully restored in this case. Critical
evaluation o her postoperative rontal view shows a downward dri t o the IMF o
a ew centimeters over time. However, NAC symmetry is good, and the volume o
tissue in the lower pole o the reconstructed breast is very close to that o the con-
tralateral normal breast.
TEACHING PO INTS
Recreating an absent IMF can be a challenge or a number o reasons. One o the
most di cult is long-term stability. Because o gravity and the weight o the breast,
there is a tendency or downward displacement. A bene t o the latissimus dorsi
f ap is its superolateral attachment high up near the axilla. This superior xation
creates a mechanical advantage. Also, the superiorly advanced abdominal tissue
in this case could pull downward against the latissimus dorsi f ap i it was not ad-
equately attached to an immobile point. In this case the abdominal advancement
f ap was sutured directly to the rib periosteum with permanent heavy sutures. Fi-
nally, no matter how good the surgeon’s judgment, it is extremely di cult to select
the correct implant volume when so many variables are involved. Because the latis-
simus dorsi f ap added volume while resection o the lower pole o the breast re-
moved volume, an adjustable implant was advantageous. Also, once a muscle unit
is divided rom its natural attachment, it will undergo volume loss rom atrophy.
Over several months the muscle can lose 60% or more o its volume; leaving the
lling port in place allows compensating adjustments to o set this unpredictable
volume loss.
BIBLIO GRAPHY
Bogucki B, Neuhaus I, Hurst EA. Dermato brosarcoma protuberans: a review o the literature. Der-
matol Surg 38:537-551, 2012.
Durkan B, Amersi F, Phillips EH, et al. Postmastectomy radiation o latissimus dorsi myocutaneous
f ap reconstruction is well tolerated in women with breast cancer. Am Surg 78:1122-1127, 2012.
Goh SC, Thorne AL, Williams G, et al. Breast reconstruction using permanent Becker expander im-
plants: an 18-year experience. Breast 21:764-768, 2012.
Hammond DC. Latissimus dorsi f ap breast reconstruction. Plast Reconstr Surg 124:1055-1063,
2009.
Losken A, Nicholas CS, Pinell XA, et al. Outcomes evaluation ollowing bilateral breast reconstruc-
tion using latissimus dorsi myocutaneous f aps. Ann Plast Surg 65:17-22, 2010.
Perdikis G, Koonce S, Collis G, et al. Latissimus dorsi myocutaneous f ap or breast reconstruction:
bad rap or good f ap? Eplasty 11:e39, 2011.
Robbins CM, Long JN, Fix RJ, et al. Mastectomy with breast reconstruction in previously augmented
patients: indications or implant removal. Ann Plast Surg 61:500-505, 2008.
Salgarello M, Rochira D, Barone-Adesi L, et al. Immediate breast reconstruction a ter skin- or nipple-
sparing mastectomy or previously augmented patients: a personal technique. Aesthetic Plast Surg
36:313-322, 2012.
Tang SS, Gui GP. A review o the oncologic and surgical management o breast cancer in the aug-
mented breast: diagnostic, surgical and surveillance challenges. Ann Surg Oncol 18:2173-2181,
2011.

11b Latissimus Dorsi Flap With Expander
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
The patient was originally seen at age 35 with a primary complaint o loss o breast
volume and skin laxity a ter having children. Also, 10 years previously, she had an
inverted-T breast reduction. At that time, she underwent a subglandular breast aug-
mentation with a periareolar mastopexy with silicone gel implants. She was satis-
ed with the improvement in shape and size postoperatively and was ollowed over
the next 3 years with no problems.
At 3 years postoperatively, she was seen or a rm nodule at the 9 o’clock posi-
tion o the right breast. The nodule appeared to be adherent to the overlying skin,
although the patient had very little breast tissue. The nodule, which was approxi-
mately 2 cm in diameter, was thought to be sitting immediately outside the breast
capsule near the anterior implant sur ace. A breast biopsy was per ormed and the
mass was ound to be sitting on the implant capsule as well as close to the skin sur-
ace. The mass was entirely excised, and pathologic evaluation revealed a tubular
carcinoma o the breast.
164

Chapter 11 • Special Problems: Malignancy After Augmentation

165
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient is thin, with minimal breast tissue. A ter the breast biopsy at the
9 o’clock position on the right breast, there is a healing 3 cm horizontal incision.
The breasts are airly symmetrical, with healed periareolar scars rom the original
augmentation mastopexy. The silicone gel implants are in a subglandular pocket.
ANALYSIS O F THE PRO BLEM
Tubular carcinoma is a relatively rare orm o breast cancer that is considered
low grade and rarely metastasizes. It is usually treated with local resection with-
out a mastectomy or adjuvant therapy. However, because this tumor developed in
a previously operated space and was in contact with both the implant capsule and
the overlying skin, a more aggressive treatment protocol was planned. We con-
sulted with both the general surgery and oncology services, and elected to do a ull-
thickness resection o the skin, breast tissue, and capsule en bloc in the area o the
biopsy as well as lower lymph node sampling.
RECOMMENDED SOLUTION TO THE PROBLEM
En bloc resection o skin, breast tissue, and implant capsule
A small latissimus dorsi myocutaneous f ap matching the size o the de ect
An adjustable expander-implant to replace the current implant

Part II: Problems in Augmentation Mammaplasty
166
TECHNIQ UE
An ellipse o skin measuring 7 by 4 cm was incised and the dissection was carried
down to the implant capsule, which was excised en bloc with the specimen. There
was only 2 to 3 cm o actual breast tissue between the skin and implant capsule.
Lower lymph node sampling was also per ormed. The patient was rotated on her
side, and a small latissimus dorsi f ap matching the dimensions o the de ect was
elevated and rotated under the axilla and brought out onto the lateral right breast
through a subcutaneous tunnel. An adjustable expander-implant was placed in the
original subglandular pocket. The latissimus dorsi muscle was used to repair the
de ect in the breast implant capsule, and the skin island replaced the local skin exci-
sion, completing the repair.
Implant
removed
Adjustable
expander-
implant
Skin
Posterior
capsule
Anterior capsule
Breast tissue
Fat

Chapter 11 • Special Problems: Malignancy After Augmentation

167
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
It was possible to closely match the original right breast by using the adjustable
implant. At 7 months postoperatively, the valve was removed through a small skin
incision. The valve had been placed on the lateral chest wall. The location o the
NAC was not changed. Typically with a local resection, the NAC position can be a
problem, but the replacement o the de ect with matching tissue prevented nipple
location malposition rom occurring.

Part II: Problems in Augmentation Mammaplasty
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TEACHING PO INTS
Although this was a relatively unusual case associated with tubular carcinoma a -
ter breast augmentation, the method o repair has broad application to many cases.
The key point here is replacing like with like to maintain the shape and contour o
the breast that was obtained with the original augmentation−periareolar masto-
pexy. This type o de ect can also be seen in patients with problems a ter lumpec-
tomy and radiation, and a small autologous f ap can requently be a solution.
Because the tumor was in contact with the original implant capsule, excision o the
capsule was necessary, and closing the capsule primarily would have distorted the
breast. There ore the latissimus dorsi f ap replaced the capsule internally and the
skin externally to restore the breast shape and contour.
It would also have been di cult to select the correct size implant, since the f ap was
now increasing the breast volume. An adjustable implant is use ul in such a case,
because it allows adjustments postoperatively as the swelling subsides and the mus-
cle atrophies. It can take several months or the so t tissue volume to stabilize a ter
a procedure in which a muscle skin f ap is used. The other bene t o an adjustable
implant is that it may limit the need or a second operation.
BIBLIO GRAPHY
Bogucki B, Neuhaus I, Hurst EA. Dermato brosarcoma protuberans: a review o the literature. Der-
matol Surg 38:537-551, 2012.
Durkan B, Amersi F, Phillips EH, et al. Postmastectomy radiation o latissimus dorsi myocutaneous
f ap reconstruction is well tolerated in women with breast cancer. Am Surg 78:1122-1127, 2012.
Goh SC, Thorne AL, Williams G, et al. Breast reconstruction using permanent Becker expander im-
plants: an 18-year experience. Breast 21:764-768, 2012.
Hammond DC. Latissimus dorsi f ap breast reconstruction. Plast Reconstr Surg 124:1055-1063,
2009.
Losken A, Nicholas CS, Pinell XA, et al. Outcomes evaluation ollowing bilateral breast reconstruc-
tion using latissimus dorsi myocutaneous f aps. Ann Plast Surg 65:17-22, 2010.
Perdikis G, Koonce S, Collis G, et al. Latissimus dorsi myocutaneous f ap or breast reconstruction:
bad rap or good f ap? Eplasty 11:e39, 2011.
Robbins CM, Long JN, Fix RJ, et al. Mastectomy with breast reconstruction in previously augmented
patients: indications or implant removal. Ann Plast Surg 61:500-505, 2008.
Salgarello M, Rochira D, Barone-Adesi L, et al. Immediate breast reconstruction a ter skin- or nipple-
sparing mastectomy or previously augmented patients: a personal technique. Aesthetic Plast Surg
36:313-322, 2012.
Tang SS, Gui GP. A review o the oncologic and surgical management o breast cancer in the aug-
mented breast: diagnostic, surgical and surveillance challenges. Ann Surg Oncol 18:2173-2181,
2011.

SEC T IO N T WO
Chapter 12 Implant Malposition
12a Pocket Modi cation With Parenchymal Scoring and Posterior Capsular Flap
12b Pocket Modi cation With Pectoralis Muscle Release
12c Asymmetrical Capsule Modi cation With Site Change
12d Capsulorrhaphy and Conversion to Submammary Pocket
12e Conversion to Neosubpectoral Pocket
12 Capsulorrhaphy With Re-creation o a Stable Lower Pole Sling With ADM to Support
an Implant
12g Form Stable Implants in a Subglandular Pocket With Revision Mastopexy and ADM
Chapter 13 Synmastia Repair
13a Synmastia Repair Using a Neosubpectoral Pocket
13b Conversion to a Subpectoral Pocket With ADM
13c Use o ADM or Treatment o Combined De ormities: Double-Bubble and Synmastia
13d Correction o Unilateral Synmastia by Conversion o Implants From Submammary
to Subpectoral
Chapter 14 Double-Bubble Deformity
14a Conversion to a Subglandular Pocket With a Capsular Flap
14b Site Change, Capsulectomy, and Conversion to Subglandular Pockets
14c Site Change to Subglandular Pockets With Mastopexy
14d Capsuloplasty and Implant Conversion to Submammary Pocket
14e Radial Capsular Scoring With Insertion o Wider-Base Implants
Chapter 15 Upper Pole Deficiency or Contour Deformity
15a Fat Gra ting to Treat Wrinkling and Contour De ormity
15b Anatomic Implants or Upper Pole De ciency
15c High Pro le Silicone Gel Implants or Correction o Rippling
Chapter 16 Inferior Pole Stretch Deformity
16a ADM and Eccentric Periareolar Mastopexy
16b Inverted-T Mastopexy With Conversion to Submuscular Silicone Gel Implants
Chapter 17 Animation Deformity Associated With Subpectoral Implants
17a Use o a Neosubpectoral Pocket
17b Conversion to Subglandular Pockets
17c Pectoralis Repositioning With ADM
Suboptimal Aesthetic Outcomes
169

Chapter 18 Overaugmented Breast
18a Mastopexy With Conversion to Submuscular Pocket
18b Conversion to Subglandular Pocket
18c Implant Replacement and ADM
18d Multidirectional Capsulorrhaphy Rein orced With ADM
Chapter 19 Ptosis in Previously Augmented Breasts
19a Conversion to Partial Subpectoral Pockets With Mastopexy
19b Neosubpectoral Pocket Exchange
19c Mastopexy Without Implant Exchange
19d Conversion to Subglandular Pockets With Periareolar Mastopexy
19e Circumareolar Mastopexy to Correct Ptosis and Other De ormities A ter Augmentation
19 Explantation and Wise Pattern Mastopexy in a Patient With Prior Augmentation-Mastopexy
Chapter 20 Asymmetries in Previously Augmented Breasts
20a Lipomodeling and IMF Fixation to Correct Asymmetry A ter Failed Breast Implants
20b Asymmetrical Mastopexies, Unilateral Volume Reduction, and Implant Replacement
Chapter 21 Explantation
21a SIEF: Simultaneous Implant Exchange With Fat Gra ting
21b Explantation Without Replacement (Mastopexy)
170