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

Part II: Problems in Augmentation Mammaplasty
172
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
Although the patient’s greatest concern is the high-riding position o her le t NAC
on the breast mound, the primary anatomic issue is the position o her implant well
below the le t IMF. A much more subtle implant malposition is noted on the right
side, with a mild double-bubble de ormity. Her right NAC sits 20 cm rom the su-
prasternal notch; her le t NAC sits 18 cm rom the suprasternal notch. The dis-
tance rom her IMF to her nipple measures 7.5 cm on her right side and 11 cm on
the le t. Her breast width is 11.5 cm bilaterally. She has a mild double-bubble de-
ormity on her right side, and her le t implant sits well below her native IMF. She
has palpable rippling in the lower pole o both breasts and has less than 3 cm o
so t tissue pinch in the upper pole o her breasts. Her le t NAC encroaches on her
tan line, and she has mature in ramammary scars. She has grade II capsular con-
tracture on the right and grade III on the le t. She is 5 eet 3 inches tall and weighs
104 pounds.
ANALYSIS O F THE PRO BLEM
This patient wanted correction o both the IMF and NAC positions on her le t side
and a more tapered look to the upper pole o her breasts. She also wanted larger
implants and correction o her capsular contracture. When using a highly cohe-
sive shaped implant, the risk o rotational problems could be minimized i the
pocket could be precisely expanded and tailored to exactly t the dimensions o the
MemoryShape implant. I she had wanted smaller implants, a round implant would
have been a better choice, because rotational problems would not be a concern
with a round implant in an oversized pocket. Although ADM could be used as an
alternative in this procedure, we thought it was unnecessary.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the saline implants and partial submuscular capsulectomy through
an in ramammary approach
Gentle scoring o the parenchyma to correct the mild double-bubble de ormity
on her right side
Using MemoryShape sizers to select implants
Selection o style MM MemoryShape 280 cc implants with an implant base di-
ameter o 12 cm, which closely approximates her preoperative breast width o
11.5 cm
Precise dissection o the submuscular pocket to the exact dimensions o the con-
toured highly cohesive implant
Re-creation o the IMF on the le t side using a superiorly based f ap o posterior
capsule le t attached to the chest wall
Placement o drains, use o Ioban sheeting to protect the implants during inser-
tion, back-f ushing through the drains with antibiotic concentrate a ter layered
closure, and use o a Biopatch around the drains

Chapter 12 • Implant Malposition

173
TECHNIQ UE
On the right breast, a subtotal anterior and posterior capsulectomy was per ormed
through an in ramammary approach to create a raw sur ace to inter ace with the
textured sur ace on the MemoryShape implant and to reduce the risk o rotation.
Gentle scoring o the parenchyma was per ormed on the right side to correct the
double-bubble de ormity. Removal o the capsule also acilitated the expansion o
the lower pole o the right breast by the shaped implant. The submuscular pocket
was enlarged to precisely t the MemoryShape Contour Pro le Gel (CPG) sizers,
and with the patient in the erect position, a style MM 280 cc implant with a base
diameter o 12 cm was chosen.
On the le t breast, a subtotal anterior and posterior submuscular capsulectomy was
per ormed, leaving the lower third o the posterior capsule attached to the chest
wall and a strip o the in erior portion o the anterior capsule le t in place on the
deep sur ace o the breast parenchyma and muscle. The correct position or the
IMF was determined with the patient in the erect position. Starting in eriorly, the
residual posterior capsule was elevated o the chest wall, and the dissection contin-
ued superiorly until the desired level o the new IMF was reached. The more supe-
rior portion o this posterior capsule was le t attached to the chest wall, creating a
superiorly based f ap. The ree in erior end o this f ap was then sutured using 3.0
Vicryl sutures to the strip o the anterior capsule that had been preserved on the
deep sur ace o the breast tissue and muscle. These sutures were le t long and un-
tied until the implant was properly positioned. The sutures were tied, and they rees-
tablished the IMF in an appropriate position. A drain was placed in each breast and
Ioban sheeting was used to cover the breasts. Then the MemoryShape Style MM
280 cc implants were positioned with a no-touch technique, and antibiotic concen-
trate was back-f ushed through the drains. A ter completion o the layered closures,
a Biopatch was applied around each o the drains.
Radial scoring to correct
double-bubble deformity
Posterior capsule
sutured to anterior
capsule to elevate
and secure IMF
Lower portion of
anterior capsule

Part II: Problems in Augmentation Mammaplasty
174
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The 11⁄2-year postoperative photos show a nice correction o the IMF position on
the le t breast with an appropriately increased implant volume and natural shape
bilaterally. Good symmetry has been reestablished and the NAC position has been
normalized on the le t side. The mild double-bubble de ormity on the right side is
no longer evident. Grade I capsules and good preservation o shape are noted on
long-term ollow-up.

Chapter 12 • Implant Malposition

175
TEACHING PO INTS
Reestablishing the IMF with capsular f aps is a power ul tool in a case such as this.
Using contoured highly cohesive implants acilitates the correction o the double-
bubble de ormity, because the implant does not de orm easily and stretches out the
so t tissue envelope in the lower pole o the breast. Tailoring the pocket to exactly
t the contoured implant minimizes the risk o implant rotation.
BIBLIO GRAPHY
Chasan PE. Breast capsulorrhaphy revisited: a simple technique or complex problems. Plast Reconstr
Surg 115:296-301; discussion 302-303, 2005.
Chasan PE, Francis CS. Capsulorrhaphy or revisionary breast surgery. Aesthet Surg J 28:63-69, 2008.
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,
2010.
Handel N, Jensen JA, Black Q, et al. The ate o breast implants: a critical analysis o complications
and outcomes. Plast Reconstr Surg 96:1521-1533, 1995.
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.
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. The neopectoral pocket in revisionary breast surgery. Aesthet Surg J 28:463-
467, 2008.
Maxwell GP, Gabriel A. Use o the acellular dermal matrix in revisionary aesthetic breast surgery. Aes-
thet Surg J 29:485-493, 2009.
Parsa FD. Breast capsulopexy or capsular ptosis a ter augmentation mammaplasty. Plast Reconstr
Surg 85:809-812, 1990.
Spear SL, Little JW III. Breast capsulorrhaphy. Plast Reconstr Surg 81:274-279, 1988.
Voice SD, Carlsen LN. Using a capsular f ap to correct breast implant malposition. Aesthet Surg J
21:441-444, 2001.
Yoo G, Lee PK. Capsular f aps or the management o malpositioned implants a ter augmentation
mammoplasty. Aesthetic Plast Surg 34:111-115, 2010.

12b Pocket Modif cation With Pectoralis Muscle Release
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 38-year-old woman had one previous breast augmentation 2 years previously.
She reported that the implants had always been sitting in a relatively high position
with signi cant superior ullness and the appearance o the NAC sitting near the
bottom o the breast mound. The patient is a healthy nonsmoker.
176

Chapter 12 • Implant Malposition

177
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has 375 cc round gel implants in place, according to her medical re-
cords. On both rontal and side view, the implants are sitting in a very high posi-
tion with signif cant superior ullness. The NAC is sitting only approximately 4 cm
above the IMF. The lower pole o the breast has inadequate projection. The patient
has no chest wall de ormities, no other abnormalities are identif ed, and she has
adequate so t tissue covering the implants, which are in a subpectoral position. The
initial surgery was done through a periareolar incision.
ANALYSIS O F THE PRO BLEM
On physical examination, when the patient was asked to contract her pectoralis
muscle, there was signif cant displacement o the implants superiorly. It appeared
that there was minimal, i any, release o the pectoralis muscle in the lower portion
o the breast, causing the implants to be displaced superiorly. In most patients the
in erior and medial attachments o the pectoralis major muscle are well above the
IMF. Failure to adequately release the in erior portion o the muscle typically causes
submuscular implants to sit too high; this also causes the NAC to appear abnor-
mally low and too close to the IMF.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the implants through the original periareolar incision
Release o the pectoralis muscle along the in erior medial attachment
Care ully limited dissection o the IMF
Location of IMF
Inferior border
of pectoralis
major muscle

Part II: Problems in Augmentation Mammaplasty
178
TECHNIQ UE
The patient underwent surgery through the original periareolar incision. When
the implant was removed, the attachments o the pectoralis muscles were still as a
whole intact in their original position along the in erior medial attachments and
had not been divided. Using a lighted retractor and cautery, and based on preop-
erative markings, the pectoralis muscles were divided along the in erior and me-
dial attachments to the breast. Temporary sizers were inserted to ensure that the
muscle dissection adequately released and that the IMF was in the proper posi-
tion. Intraoperative implant sizers assure proper muscle release and help prevent
overdissection.
Implant location
with pectoralis
major muscle intact
Periareolar
incision
Implant location
after pectoralis
major muscle release
Pectoralis
major muscle
released

Chapter 12 • Implant Malposition

179
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
It can be seen in both the anterior and oblique views that the major problem in this
patient was the inadequate release o the muscle, which caused the implant to ride

Part II: Problems in Augmentation Mammaplasty
180
abnormally high. Through the original periareolar incision, the muscle was success-
ully divided and gave a signi cant improvement in the patient’s contour.
This patient had a signi cant improvement with a relatively simple procedure. This
nipple is now in a more centralized location on the breast mound, and the distance
rom the bottom o the areola to the IMF increased rom 4 cm to over 6 cm.
TEACHING PO INTS
When inserting subpectoral implants, the surgeon must ensure that there is ade-
quate and appropriate release o the pectoralis muscle when dissecting the pocket,
especially when the nipple is in a slightly low starting position. This patient dem-
onstrated a very typical example o inadequate muscle release. E ective intraop-
erative assessment o the muscle release along the in erior medial edge o the pec-
toralis muscle was achieved by inserting sizers and sitting the patient up during the
surgery.
BIBLIO GRAPHY
Castello MF, Lazzeri D, Silvestri A, et al. Maximizing the use o precapsular space and the choice o
implant type in breast augmentation mammaplasty revisions: review o 49 consecutive proce-
dures and patient satis action assessment. Aesthetic Plast Surg 35:828-838, 2011.
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.
Lesavoy MA, Trussler AP, Dickinson BP. Di culties with subpectoral augmentation mammaplasty
and its correction: the role o subglandular site change in revision aesthetic breast surgery. Plast
Reconstr Surg 125:363-371, 2010.
Maxwell GP, Gabriel A. E cacy o acellular dermal matrices in revisionary aesthetic breast surgery: a
6-year experience. Aesthet Surg J 33:389-399, 2013.
Maxwell GP, Birchenough SA, Gabriel A. E cacy o neopectoral pocket in revisionary breast surgery.
Aesthet Surg J 29:379-385, 2009.
Médard de Chardon V, Balaguer T, Chignon-Sicard B, Lebreton E. Double breast contour in primary
aesthetic breast augmentation: incidence, prevention and treatment. Ann Plast Surg 64:390-396,
2010.
Shestak KC. Acellular dermal matrix inlays to correct signi cant implant malposition in patients with
compromised local tissues. Aesthet Surg J 31(7 Suppl):85S-94S, 2011.
Slavin SA, Lin SJ. The use o acellular dermal matrices in revisional breast reconstruction. Plast Recon-
str Surg 130(5 Suppl 2):70S-85S, 2012.

12c Asymmetrical Capsule Modif cation
With Site Change
El iz a bet h J. h a l l -Fin d l ay
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 44-year-old patient had had saline implants placed in a subglandular position
20 years previously. She had one child, and later developed a right capsular con-
tracture (Baker grade III) with malposition.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The implant is sitting in the lower pole o the right breast, which makes the nipple
look quite high.
181

Part II: Problems in Augmentation Mammaplasty
182
The actual measurement rom the suprasternal notch to the nipple as measured
along the skin is 21 cm on both sides. In other words, correction o the implant
malposition should correct the nipple position as well.
ANALYSIS O F THE PRO BLEM
The problem was not only capsular contracture on the right side with distortion,
but also the right nipple appeared to be high because the majority o the implant
was in the lower pole. To correct the nipple position, the bottom-heavy breast
mound needs to be corrected.
RECOMMENDED SOLUTION TO THE PROBLEM
Site change, because the implants are in a subglandular pocket and capsular con-
tracture has developed on the right side
Complete capsulectomy
Care ul attention to hemostasis to help prevent recurrent contracture

Chapter 12 • Implant Malposition

183
TECHNIQ UE
On the right side, a capsulectomy was per ormed, ollowed by a site change. The
350 cc saline implants were replaced with smooth walled cohesive silicone gel SSM
365 cc implants. The capsule had an eggshell consistency with a chalklike substance
clinging to the inner sur ace. The pocket was closed with interrupted 3-0 PDS su-
tures to prevent migration o the implant back into the subglandular pocket. A
subpectoral dual plane pocket was created superiorly. The in erior dead space was
closed by suturing the in erior f ap to the chest wall. On the le t breast, the superior
capsule was removed and the pocket closed with 3-0 PDS in a similar ashion. The
lower capsule was elevated o the chest wall and a capsulorrhaphy per ormed by
closing the dead space in eriorly and suturing the reed capsule.
Pocket closed with
interrupted sutures
Inferior flap sutured
to chest wall
Right side
Superior capsule
removed and
pocket closed
Lower capsule
elevated to close
inferior dead space
Left side

Part II: Problems in Augmentation Mammaplasty
184
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 6 weeks a ter surgery. Note the improvement in the nipple
position on the right side rom both the rontal and lateral views. The patient is
shown again at 14 months a ter surgery. There has been some bottoming out o the
right implant with some loss o correction. Converting implants to the subpectoral
position may potentially allow the muscle to push the implant downward.
Preoperative
6 weeks postoperatively
14 months postoperatively

Chapter 12 • Implant Malposition

185

6 weeks postoperatively
14 months postoperatively

Part II: Problems in Augmentation Mammaplasty
186
TEACHING PO INTS
The problem initially appeared to be nipple malposition but instead turned out
to be implant malposition creating an abnormal mound shape. This shape was
bottom-heavy and gave the appearance o a high nipple.
A site change may eventually be a good idea, but only time will tell. With this pro-
cedure, the idea was to create a resh pocket in an attempt to avoid inciting a cap-
sular contracture. Un ortunately, once bottoming out starts to occur, the problem
will likely be exacerbated, because the muscle will keep pushing the implant down.
The pectoralis only covers the upper pole o the implant, and contraction o this
muscle compresses the upper pole and causes urther bottoming out.
BIBLIO GRAPHY
Chasan PE, Francis CS. Capsulorrhaphy or revisionary breast surgery. Aesthet Surg J 28:63-69, 2008.
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.
Maxwell GP, Gabriel A. The neopectoral pocket in revisionary breast surgery. Aesthet Surg J 28:463-
467, 2008.
Okoro SA, Wang HT, Levine RA. Percutaneous preoperative implant def ation: the treatment o breast
stretch de ormity and implant malposition. Aesthetic Plast Surg 33:243-245, 2009.
Parsa FD. Breast capsulopexy or capsular ptosis a ter augmentation mammaplasty. Plast Reconstr
Surg 85:809-812, 1990.
Spear SL, Little JW III. Breast capsulorrhaphy. Plast Reconstr Surg 81:274-279, 1988.
Voice SD, Carlsen LN. Using a capsular f ap to correct breast implant malposition. Aesthet Surg J
21:441-444, 2001.
Yoo G, Lee PK. Capsular f aps or the management o malpositioned implants a ter augmentation
mammaplasty. Aesthetic Plast Surg 34:111-115, 2010.

12d Capsulorrhaphy and Conversion to Submammary
Pocket
Nea l h a n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 28-year-old nulliparous woman presented 6 years a ter having breast augmen-
tation with subpectoral saline- lled implants. She stated that her initial result was
“good”; however, over a period o about 2 years, she noted gradual dropping o the
le t implant. By the time she presented or corrective surgery, the le t breast implant
had descended signi cantly in eriorly and slightly laterally, and she had moderate
Baker grade II capsular contracture on the right side. Preoperative rontal, oblique,
and lateral views demonstrate the bottoming out o the le t breast implant as well
as lateral malposition o the le t implant, causing widening o the cleavage area.
The patient only requested correction o her implant malposition; she was happy
with the size o her breasts.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient is a healthy young woman who had previously undergone bilateral
augmentation mammaplasty; she has well-healed in erior periareolar scars. She has
round smooth saline- lled implants in the subpectoral position. Her breasts are
very asymmetrical, with in erior and lateral malposition o the le t implant. The
right breast, which is Baker grade II, is slightly rmer than is desirable.
ANALYSIS O F THE PRO BLEM
This patient presented with in erior malposition o her le t breast implant, which is
bottoming out. Implant malposition can present as an early postoperative compli-
cation, in which case it typically is caused by a technical error in pocket dissection,
or as a delayed phenomenon, as in this case. Bottoming out and lateral implant
malposition are more common with saline implants than with silicone gel implants,
and more common with implants in the subpectoral rather than submammary posi-
187

Part II: Problems in Augmentation Mammaplasty
188
tion. The downward and lateral orce vector exerted on a subpectoral implant each
time the muscle is either volitionally or involuntarily activated contributes to im-
plant malposition. In erior and/or lateral implant malposition is generally corrected
by some type o pocket modi cation such as capsulorrhaphy, capsuloplasty, or cap-
sular f ap advancement, or by conversion o the implant into a new virgin pocket.
Additionally, in patients with subpectoral implants, switching to the submammary
position should be considered, because this will eliminate the orces that may have
contributed to implant displacement and will greatly reduce the risk o recurrence
o the de ormity. Patients with saline- lled implants should be given the option o
replacement with silicone gel implants, which may not only give a superior cos-
metic result but also will have less tendency to late displacement because o di er-
ences in the e ciency with which saline and silicone gel implants transmit “hydrau-
lic” orces into adjacent so t tissues.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the previous subpectoral saline implants through the existing scars
Per orming capsuloplasty to reduce the in erior and lateral dimensions o the
pocket
Creation o a new submammary pocket with secure xation o the pectoral
muscle to the chest wall
Insertion o a new pair o smooth silicone gel implants
TECHNIQ UE
On the operating table preoperative markings were made to delineate the medial
extent o dissection o the new submammary pocket; the existing implants were ac-
cessed through the old periareolar scars. A ter removing the saline implants, we vi-
sualized the capsule that was lining the undersur ace o the pectoral muscle and the
subadjacent chest wall.

Chapter 12 • Implant Malposition

189
Cautery was used to roughen the capsule on the undersur ace o the pectoral mus-
cle, creating a raw sur ace to promote secure adhesion o the muscle to the chest
beneath. The posterior capsule (lining the chest wall) was resected to create a raw
tissue sur ace to promote adherence to the pectoral muscle. The leading edge o the
pectoral muscle was then grasped and cautery dissection used to create a new sub-
mammary pocket. The pectoral muscle was brought into approximation with the
chest wall, and a silicone rubber drain was interposed between the muscle and chest
to drain any f uid that might accumulate and prevent reattachment o the muscle.
The muscle was sutured to the chest with interrupted gure-o -eight PDS absorb-
able sutures. A design or capsuloplasty was then drawn, centered on the in erior
axis o the periprosthetic pocket; the width o the ellipse was twice the distance
that the old had to be raised.

Part II: Problems in Augmentation Mammaplasty
190
An elliptical piece o scar tissue capsule was resected, hemostasis secured, and the
capsulorrhaphy was per ormed. I there is a signi cant amount o dead space to be
closed, a layered closure may be per ormed, generally using long-lasting absorbable
sutures, such as PDS suture, in the deep layers and a running locked nonabsorbable
suture (Prolene or nylon) in the capsule. The newly con gured submammary pocket
was then ready or insertion o a smooth round silicone gel prosthesis. Identical
steps, with the exception o capsulorrhaphy, were per ormed on the right side.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient had an unevent ul postoperative course and a good result. Postopera-
tive photos demonstrate complete correction o the bottoming out o the le t breast
implant.

Chapter 12 • Implant Malposition

191
Her IMFs are symmetrical and the le t implant has been repositioned medially to
improve cleavage. Because the implants are in the submammary position, chances
are very good that the correction will be long-lasting. The patient has the additional
bene t o having more natural- eeling breasts because o the conversion to silicone
gel implants. Her postoperative result is shown at 8 months.
TEACHING PO INTS
This case illustrates just one approach that may be used to correct bottoming out o
breast implants. Downward and lateral implant malposition is more common with
saline implants than with silicone gel implants and is more likely to occur when im-
plants are placed subpectorally rather than in submammary pockets. This is caused
by the continuous downward and lateral orce vector applied to the implant every
time the pectoral muscle is f exed. Some recon guration o the pocket is usually re-
quired, such as capsuloplasty, a capsular advancement f ap, or creation o a virgin
pocket in a new plane. Conversion to the submammary position, as per ormed in
this case, is a use ul adjunct to ensure a long-lasting correction and to reduce i not
totally eliminate the possibility o recurrent bottoming out.
BIBLIO GRAPHY
Chasan PE. Breast capsulorrhaphy revisited: a simple technique or complex problems. Plast Reconstr
Surg 115:296-301, 2005.
Handel N. Managing complications o augmentation mammaplasty. In Spear SL, ed. Surgery o the
Breast: Principles and Art, 3rd ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins,
2011.
Handel N, Jensen JA, Black Q, et al. The ate o breast implants: a critical analysis o complications
and outcomes. Plast Reconstr Surg 96:1521-1533, 1995.
Spear SL, Little JW III. Breast capsulorrhaphy. Plast Reconstr Surg 81:274-279, 1988.

12e Conversion to Neosubpectoral Pocket
El iz a bet h J. h a l l -Fin d l ay
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 50-year-old patient had her original breast augmentation 25 years previ-
ously. She is 5 eet 7 inches tall and weighs 130 pounds. She had subpectoral gel-
saline implants, which had been inserted through transaxillary incisions. The right
implant was high riding, especially with animation, so she underwent a revision
through in ramammary incisions. There was no saline le t, but the gel was intact
and was approximately 325 cc. The implants were replaced with smooth-walled gel
implants, 500 cc each. The surgeon had noted that the pocket extended up toward
the axilla on the right side, so the pocket was closed o with dissection and sutures
both superiorly and laterally.
192

Chapter 12 • Implant Malposition

193
The patient started li ting weights earlier than recommended by her surgeon. She
elt a “pop” and the implant shi ted back to the elevated position on the right side.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The right breast implant is again sliding back into the tunnel that had been created
by the original transaxillary dissection.
ANALYSIS O F THE PRO BLEM
It is important to close o the pocket completely to prevent recurrent displacement.
Cautery o the capsule alone is not likely to be e ective, and sutures alone will not
close the pocket. The capsule needs to be removed and sutures must be used to
close the pocket, but even then the sutures may give way, as they did in this patient.
RECOMMENDED SOLUTION TO THE PROBLEM
Because the revision had been per ormed by an accomplished and competent sur-
geon, it was prudent to choose a di erent approach to try to solve the problem:
Creation o a completely new pocket using the neosubpectoral technique, as
described by Spear

Part II: Problems in Augmentation Mammaplasty
194
TECHNIQ UE
The in ramammary incision was used and a neosubpectoral pocket was created.
Sometimes a completely new pocket is needed in eriorly, which can be quite di -
cult to create. It was much easier to ashion a neosubpectoral pocket superiorly
so that the implant would not be able to displace superiorly and laterally when the
pectoralis muscle was contracted.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The postoperative result is shown at 2 months.
Creation of
neosubpectoral
pocket
Original pocket
closed and sutured
to chest wall

Chapter 12 • Implant Malposition

195
Good correction o the implant malposition is shown both at rest and with anima-
tion.
TEACHING PO INTS
We are o ten reminded that the sign o a ool is to repeat the same approach and
expect a di erent result. Although the original approach o closing o the pocket
may have worked in some patients, the act that it was unsuccess ul in this patient
mandated a di erent approach. The same approach with strict instructions not
to work out might have worked. However, in this case creating a neosubpectoral
pocket and inserting the implant into a virgin space was e ective in preventing the
implant rom sliding back into the original malposition.

Part II: Problems in Augmentation Mammaplasty
196
BIBLIO GRAPHY
Chasan PE, Francis CS. Capsulorrhaphy or revisionary breast surgery. Aesthet Surg J 28:63-69, 2008.
Lee HK, Jin US, Lee YH. Subpectoral and precapsular implant repositioning technique: correction o
capsular contracture and implant malposition. Aesthet Surg J 35:1126-1132, 2011.
Maxwell GP, Gabriel A. The neopectoral pocket in revisionary breast surgery. Aesthet Surg J 28:463-
467, 2008.
Okoro SA, Wang HT, Levine RA. Percutaneous preoperative implant def ation: the treatment o breast
stretch de ormity and implant malposition. Aesthetic Plast Surg 33:243-245, 2009.
Parsa FD. Breast capsulopexy or capsular ptosis a ter augmentation mammaplasty. Plast Reconstr
Surg 85:809-812, 1990.
Spear SL, Little JW III. Breast capsulorrhaphy. Plast Reconstr Surg 81:274-279, 1988.
Voice SD, Carlsen LN. Using a capsular f ap to correct breast implant malposition. Aesthet Surg J
21:441-444, 2001.
Yoo G, Lee PK. Capsular f aps or the management o malpositioned implants a ter augmentation
mammaplasty. Aesthetic Plast Surg 34:111-115, 2010.

12 Capsulorrhaphy With Re-creation o a Stable Lower
Pole Sling With ADM to Support an Implant
Gl y n Jo n es
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 30-year-old woman underwent bilateral symmetrical subpectoral augmenta-
tion with gel implants through in ramammary incisions by another surgeon. Post-
operatively she was noted to have descent o the right in ramammary crease. Her
surgeon reoperated twice in an e ort to per orm suture capsulorrhaphy, with dete-
riorating results with each successive intervention.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
By the time she presented or consultation, her right breast crease was almost 4 cm
lower than her le t breast.
ANALYSIS O F THE PRO BLEM
The IMF o the right breast was approximately 4 cm lower than that o the le t.
This resulted in descent o the implant down the chest wall and lengthening o the
distance o the IMF to the nipple on the a ected side. As a result o the malposition
o the old, the patient was unable to wear a bra without its strap rising up over the
lower pole o the breast.
197

Part II: Problems in Augmentation Mammaplasty
198
RECOMMENDED SOLUTION TO THE PROBLEM
Right capsulorrhaphy with re-creation o a stable lower pole sling to support the
implant
Insertion o a sheet o Strattice ADM
TECHNIQ UE
The right IMF was opened and the implant removed. Using 2-0 Ethibond nonab-
sorbable sutures, a sheet o 8 by 16 cm thick ADM was sutured to the periosteum
o the th rib along its anterior sur ace and convexity. The implant was then re-
inserted beneath the pectoralis major muscle superiorly, with the ADM orming
an in erior sling to support the implant in eriorly. The ADM was draped over the
lower pole o the implant and sutured to the caudal border o the pectoralis major
muscle and the anterior breast capsule using 2-0 PDS sutures. A drain was then in-
serted and le t in place or 5 days.
ADM sutured to
pectoralis major muscle
ADM sutured
to chest wall

Chapter 12 • Implant Malposition

199
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 9 months postoperatively with retention o the capsulorrha-
phy and good symmetry. No attenuation o the ADM sling has occurred. Arm el-
evation is shown to demonstrate crease symmetry with the ADM in place.

Part II: Problems in Augmentation Mammaplasty
200
TEACHING PO INTS
The position o the breast crease on the a ected side should exactly mirror that
on the normal side. Capsulorrhaphy is a di cult procedure to secure adequately
and hold in place permanently. Suturing should be per ormed with nonabsorbable
heavy-duty sutures anchored to the rib periosteum and adjacent muscle. The use o
ADM can signi cantly improve results by rein orcing lower pole support.
BIBLIO GRAPHY
Chasan PE. Breast capsulorrhaphy revisited: a simple technique or complex problems. Plast Reconstr
Surg 115:296-301; discussion 302-303, 2005.
Hartzell TL, Taghinia AH, Chang J, et al. The use o human acellular dermal matrix or the correc-
tion o secondary de ormities a ter breast augmentation: results and costs. Plast Reconstr Surg
126:1711-1720, 2010.
Maxwell GP, Gabriel A. Acellular dermal matrix in aesthetic revisionary breast surgery. Aesthet Surg J
31(7 Suppl):65S-76S, 2011.
Pozner JN, White JB, Newman MI. Use o porcine acellular dermal matrix in revisionary cosmetic
breast augmentation. Aesthet Surg J 33:681-690, 2013.
Shestak KC. Acellular dermal matrix inlays to correct signi cant implant malposition in patients with
compromised local tissues. Aesthet Surg J 31(7 Suppl):85S-94S, 2011.
Slavin SA, Lin SJ. The use o acellular dermal matrices in revisional breast reconstruction. Plast Recon-
str Surg 130(5 Suppl 2):70S-85S, 2012.

12g Form Stable Implants in a Subglandular Pocket
With Revision Mastopexy and ADM
Br ia n d . Pet er so n
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 33-year-old nulliparous bodybuilder underwent initial subpectoral breast aug-
mentation with 300 cc textured saline implants and simultaneous vertical masto-
pexies. The submuscular saline implants had migrated in erolaterally. The correc-
tion incorporated revision augmentation, changing to subglandular textured orm
stable implants, use o ADM to stabilize the position o the IMF and coverage o
the implant, and revision o the mastopexy.
201

Part II: Problems in Augmentation Mammaplasty
202
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
Wide separation o the implants is evident as a result o in erolateral displacement
caused by the strong contractile orces o the pectoralis major muscle. Attachment
o the pectoralis muscle is seen just below the areola, with a secondary lower pole
double-bubble de ormity. An increased areola-IMF distance o 10 cm on the right
and 9 cm on the le t with secondary bottoming out o the implants is shown.
ANALYSIS O F THE PRO BLEM
As shown in the prerevision photos, the initial release o the pectoralis muscle rom
its costal origin has allowed it to “window shade” upward while at the same time,
the strong contractile orce o the muscle has pushed the implant downward and
lateral, causing it to bottom out. Combined with the vertical mastopexy, this has
placed the NAC proportionately too high and the in ramammary crease too low.
RECOMMENDED SOLUTION TO THE PROBLEM
Bilateral implant removal
Anterior capsulectomies
Creation o subglandular pockets
Suturing o the pectoralis muscle to the chest wall with permanent sutures
Replacement with orm stable cohesive gel implants
Revision mastopexies
Suturing o the chest wall f ap to the chest wall and rein orcement with ADM
TECHNIQ UE
Because o the strong action o the pectoralis major muscle and subsequent in ero-
lateral implant displacement, a change o plane was required. The subpectoral tex-
tured saline implants were removed and an anterior capsulectomy was per ormed.
A subglandular pocket was created, and the pectoralis muscle sutured to the chest
wall with permanent sutures. Form stable, moderate height, moderate pro le, cohe-
sive 360 cc gel implants were placed in a subglandular pocket.
Revision mastopexy was per ormed, leaving the previous vertical scar intact but
creating an IMF incision. The distance rom the areola to the IMF was shortened to
6 cm. The chest wall f ap was advanced cephalad and sutured to the chest wall and
the repair line rein orced with ADM, which was then sutured to the undersur ace
o the glandular tissue to urther enhance implant support.

Chapter 12 • Implant Malposition

203
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The postoperative photos show the patient 2 years a ter the revision.

Part II: Problems in Augmentation Mammaplasty
204
The IMF position has been maintained, and perhaps there is some tissue “over-
old” redundancy, because tissue overlap at the lateral end o the IMF is seen in the
oblique and lateral views. Since the displacing orce o the pectoralis muscle has
been eliminated, the implants are maintaining their position; the anatomic orm
stable implant may have helped accomplish this, and it also provides “normal” con-
tour without the upper pole de ormity o ten seen with round implants.
TEACHING PO INTS
The use o subpectoral implants in patients with strong displacing orces may re-
sult in in erolateral displacement when the costal origin o the pectoralis muscle is
released. Subsequent attachment o the lower border o the pectoralis muscle to the
overlying breast tissue may cause a double-bubble lower pole de ormity, especially
when there is relaxation o the lower pole glandular tissue.
Changing to an anatomic-shaped subglandular implant will improve breast con-
tour. Creation o a neopocket in addition to revision mastopexy using ADM will
rein orce the IMF and help to prevent recurrent implant displacement.
BIBLIO GRAPHY
Bengston BP, Van Natta BW, Murphy DK, et al; Style 410 US 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.
Breuing KH, Warren SM. Immediate bilateral breast reconstruction with implants and in erolateral
AlloDerm slings. Ann Plast Surg 55:232-239, 2005.
Drever JM. Cohesive gel implants or breast augmentation. Aesthet Surg J 23:405-409, 2003.
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.
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.
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.
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.

C h a p t e r 13
SYNMASTIA REPAIR
13a Synmastia Repair Using a Neosubpectoral Pocket
Jer emy C. Sin k in , Sc o t t L. Spea r
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
The patient is a 28-year-old woman who presented with recurrent synmastia. She
had initially undergone bilateral partial submuscular augmentation mammaplasty
by another surgeon 1 year earlier. She had high pro le 330 cc saline implants lled
to 390 cc bilaterally. Shortly a ter that procedure, the patient noted the develop-
ment o synmastia. Her original surgeon attempted to repair the synmastia through
medial capsulorrhaphy 7 months a ter her initial breast augmentation. Un ortu-
nately the synmastia repair was unsuccess ul, and the patient sought a second opin-
ion at our o ce or correction o her recurrent de ormity.
The patient is an otherwise healthy individual without any major medical prob-
lems. In addition to the surgical procedures mentioned, she had a previous right
breast biopsy with normal ndings.
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Part II: Problems in Augmentation Mammaplasty
206
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has extreme medial border malposition bilaterally, resulting in loss o
the appropriate medial boundary o her breasts. The rontal view reveals the medial
malposition o her implants, which causes her nipples to appear to sit too ar later-
ally on her breasts.
Additionally she has a prominent in ramammary scar on her le t breast rom her
previous surgeries, contributing to a peculiar breast shape with an abrupt f attening
o the normal lateral convexity. Her current implants are high pro le, but we con-
clude the base diameter is too small or her chest.
ANALYSIS O F THE PRO BLEM
Synmastia is a breast de ormity de ned as extreme medial old malposition, which
results in e acement o the intermammary sulcus. This de ormity arises rom over-
dissection o one or both breast implant pockets at the midline, and may conse-
quently unite the two pockets. Extreme medialization o the breasts not only dis-
torts the decolletage aesthetic, but may also impair a woman’s ability to t into a
brassiere and may subsequently have detrimental e ects on sel -image.
Strategies or the correction o synmastia include simple suture repair with or with-
out the creation o capsular f aps, incorporation o acellular dermal matrices, and
relocation o implants rom either the subglandular to submuscular plane, or vice
versa. This patient had already had one attempted repair o her synmastia with a
capsulorrhaphy that did not prove durable. Additionally, because her implants were
subpectoral and it was thought she could bene t rom larger implants, we chose to
maintain the current submuscular location but to create a neosubpectoral pocket.
Creation o a new implant pocket allows the surgeon to precisely control the extent
o medial old dissection. Dissection o a new pocket does not carry the same risk
o synmastia recurrence inherent in other techniques in which an attempt is made
to seal o the existing medial pocket border.

Chapter 13 • Synmastia Repair

207
RECOMMENDED SOLUTION TO THE PROBLEM
Exchange o her implants to larger, silicone gel implants
Creation o a neosubpectoral pocket
Scar revision
TECHNIQ UE
The patient’s markings are shown.
To gain access to the le t implant, the old in ramammary scar was excised sharply
a ter in ltration o local 0.5% lidocaine with epinephrine. Subglandular dissection
using a lighted electrocautery was per ormed between the breast and the anterior
capsule o the lower pole o the breast implant until the in erior border o the pec-
toralis major muscle was identi ed. The anterior sur ace o the capsule was dis-
sected care ully to ree the capsule rom the undersur ace o the pectoralis muscle;
we were particularly care ul to avoid dissecting too ar medially, and in act we un-
derdissected medially at this point o the operation. This new plane o dissection, or
neosubpectoral pocket, ormed the pocket or placement o the new implant. The
anterior capsule was then incised in eriorly and the old implant removed.
Displacement
of implants
Dissection of
neosubpectoral
pocket
Medial
capsulorrhaphy
Previous
pocket collapsed
and sutured to
chest wall
Implant
placed in
neopectoral
pocket

Part II: Problems in Augmentation Mammaplasty
208
To close o the old synmastia pocket, a capsulorrhaphy using a 2-0 PDS running
stitch was done medially, and the remainder o the old capsule was obliterated with
several additional interrupted sutures between the anterior and posterior capsule
walls. At this point, we had already partly developed a new space or the implant in
the neosubpectoral pocket that we had dissected earlier, anterior to the old capsule
and deep to the muscle superiorly, and deep to the gland in eriorly. A 425 cc high
pro le silicone gel implant sizer was placed rst to assess the neopocket dimensions
and the implant size. Then the same size implant was placed and the incision was
closed in layers, including the super cial tissues and skin. The identical procedure
was per ormed on the contralateral side.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
Photographs o the patient taken 14 months a ter surgery demonstrate a stable and
success ul repair. The rontal view shows that she has a more appropriate inter-
mammary distance. Her breasts are larger, and she has a uller, more natural ap-
pearance to her lateral breast contour.

Chapter 13 • Synmastia Repair

209
TEACHING PO INTS
Synmastia is a rare but troublesome complication o breast augmentation. It com-
monly results rom overdissection medially during the initial creation o the im-
plant pocket or during a revision o an earlier breast augmentation, resulting in
displacement o the implant beyond the midline. A number o di erent repair tech-
niques have been described. This patient had a ailed previous primary suture repair
o her synmastia, necessitating a di erent strategy. Simple exchange o the implants
to a subglandular plane in this patient might have been another option, but it
would not have been ideal, because the lower hal o the previous pocket was also
subglandular, and there was minimal breast tissue to cover the implant, particularly
superiorly. We thought that she would bene t rom larger implants to better match
her anatomy and ll out the lateral curvature o her breasts, but larger implants
would likely have been more palpable and unnatural in the subglandular space. A
previous attempt at medial capsulorrhaphy had ailed, and we reasoned that plac-
ing larger implants back in the old subpectoral space a ter another capsulorrhaphy
would likely ail because o the stress on the repair i a submuscular capsulorrha-
phy were attempted.
When de ning the neosubpectoral pocket, the potential or trouble by overdissec-
tion is highest when dissecting the plane medially. It is easiest to develop the plane
between the anterior capsule and pectoralis muscle when the capsule is le t intact
and the implant is in place, providing countertension. The surgeon must be very
mind ul to avoid ollowing the curvature o the implant completely and to stop
short o the anticipated medial border o the new pocket.
BIBLIO GRAPHY
Spear SL, Dayan JH, Bogue D, et al. The “neosubpectoral” pocket or the correction o symmastia.
Plast Reconstr Surg 124:695-703, 2009.

13b Conversion to a Subpectoral Pocket With ADM
Jer emy C. Sin k in , Sc o t t L. Spea r
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 52-year-old woman presented to us or correction o synmastia. Sixteen years
earlier, at another institution, she had undergone bilateral subglandular breast aug-
mentation by a transumbilical approach, and 240 cc saline implants were placed at
that time. Subsequently, the patient elt a breast lump in her right breast and had a
breast biopsy o a benign mass with concurrent implant exchange to 250 cc moder-
ate plus pro le gel implants. The patient was not happy with her appearance a ter
this exchange; she elt that the implants were too narrow. She then underwent im-
plant revision with ADM; the implants were exchanged or larger 375 cc moderate
pro le cohesive gel implants with a larger base width (14.5 cm). Un ortunately, the
patient developed synmastia and complained o implant palpability and rippling,
or which she sought a second opinion or correction. The patient’s past medical
history included atrial brillation, mitral valve prolapse, and Reynaud’s syndrome.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
On rontal view it can be seen that the patient has no measurable intermammary
distance.
210

Chapter 13 • Synmastia Repair

211
ANALYSIS O F THE PRO BLEM
On close evaluation, it was the medial old o her le t breast that crossed the mid-
line. Because o the medial displacement o her breasts, her nipples appeared to be
positioned too ar laterally, particularly the le t breast. Her le t breast was larger
than her right. The patient was particularly thin, her implants were easily palpable,
there was minimal breast tissue, and her upper pole pinch test demonstrated mini-
mal so t tissue cover.
RECOMMENDED SOLUTION TO THE PROBLEM
Exchange o the implants to a narrower base width
Change rom a subglandular to a subpectoral plane
Le t medial pocket synmastia repair
Rein orcement with ADM to buttress the repair
TECHNIQ UE
The patient’s breasts were marked. The prior IMF incisions were in ltrated with
0.5% lidocaine with epinephrine, and the le t breast scar was sharply excised. Us-
ing a lighted electrocautery device, the incision was deepened in the subglandular
plane until the periprosthetic capsule was reached. Dissection was carried superi-
orly along the anterior sur ace o the capsule or another 3 cm, then the capsule
was incised and the old implant removed.

Part II: Problems in Augmentation Mammaplasty
212
Intraoperatively, it can be seen how the old implant pocket extended medially be-
yond the midline. The posterior sur ace o the capsule was then care ully dissected
o the chest wall until the in erior border o the pectoralis major was reached. The
pectoralis major was elevated to create the subpectoral pocket. Care was taken not
to elevate the muscle excessively, because the cut edge o the muscle would serve as
the medial border o the new pocket.
Implant removed and subglandular
pocket collapsed over pectoralis
major muscle
Dissection of
subpectoral
pocket
Superior and
interior marionette
sutures
ADM sutured
to chest wall
Subpectoral
pocket
Implant placed in
subpectoral pocket

Chapter 13 • Synmastia Repair

213
To buttress the new medial old, an 8 by 8 cm piece o ADM was inset into the new
pocket and secured on the anterior sur ace superiorly and in eriorly with mari-
onette sutures through-and-through the muscle and the overlying breast tissue, in-
cluding the skin. The posterior edges o the ADM were secured to the chest wall
with interrupted 3-0 PDS sutures.
Revision o the right breast augmentation was approached in a similar ashion. The
subglandular capsule was exposed through the previous IMF incision and a subpec-
toral pocket created. No ADM was needed to rein orce the right medial old.
Hemostasis was ensured and the pockets were irrigated with diluted Betadine ol-
lowed by triple antibiotic solution, then the new smooth round moderate pro le
375 cc silicone gel implants (base width 12.8 cm) were placed. The medial olds o
the le t and right pockets were double-checked to con rm that they were 2 cm lat-
eral to the midline. The incisions were closed in layers over closed suction drains.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient had immediate and sustained improvement o her intermammary dis-
tance at each postoperative ollow-up. Un ortunately, 3 months a ter surgery,
during some heavy li ting, the patient experienced intense pain in the le t breast,
associated with a 1 cm descent o her le t in ramammary old. She subsequently un-
derwent a revision with a capsulorraphy o the le t IMF, which was rein orced with
a strip o ADM along the IMF. Fi teen-month postoperative photos show improve-
ment and sustained repair o her synmastia.

Part II: Problems in Augmentation Mammaplasty
214
TEACHING PO INTS
In this case, repair o the patient’s synmastia involved three distinct maneuvers. The
rst was to move the patient’s implants rom a subglandular position to a new sub-
pectoral plane. Dissection o the new pocket in the submuscular plane allowed pre-
cise control over the medial extent o the implant. Second, because the previous le t
breast implant was displaced medially, the overlying so t tissues were thin. ADM
was draped medially to rein orce the thinned medial boundary. Third, the patient’s
implants were exchanged or a pair with a smaller base width to reduce the tension
on the medial old.
When using ADM to rein orce a capsulorrhaphy, it is important to use a piece large
enough to span the entire de ect, so the anterior edge can be sewn to the muscle or
anterior capsule and the posterior edge can be sewn to the chest wall or posterior
capsule with 2 to 3 cm o overlap.
BIBLIO GRAPHY
Curtis MS, Mahmood F, Nguyen MD, et al. Use o AlloDerm or correction o symmastia. Plastic Re-
constr Surg 126:192e-193e, 2010.
Slavin S, Lin S. The use o acellular dermal matrices in revisional breast reconstruction. Plast Reconstr
Surg 130(5 Suppl 2):70S-85S, 2012.
Spear S, Seruya M, Clemens MW, Teitelbaum S, Nahabedian MY. Acellular dermal matrix or
the treatment and prevention o implant-associated breast de ormities. Plast Reconstr Surg
127:1047-1058, 2011.

13c Use of ADM for Treatment of Combined
Deformities: Double-Bubble and Synmastia
Nea l h a n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 48-year-old woman underwent breast augmentation in Australia in her mid-
twenties with 300 cc saline- lled implants. She later wanted larger breasts, so in
2007, her prostheses were replaced with 575 cc saline implants. Then the patient
thought her cleavage was “too wide,” so in 2008, she underwent revision with in-
sertion o 600 cc Mentor smooth round silicone gel implants. The patient was re-
erred or treatment o multiple de ormities including synmastia, skin rippling that
was more pronounced on the right breast, and bilateral double-bubble de ormity.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
When her arms are held up, the olds appear asymmetrical, and the increased arc
length on the right side is even more apparent. When the patient f exes her pectoral
muscles, it is obvious that there is a bilateral double-bubble, slightly worse on the
right side.
The patient is a slender woman with
bilateral subpectoral breast implants.
She has well-healed in ramammary
scars on both breasts. At rest the le t
breast appears normal, but the right
breast is characterized by a subtle
double-bubble de ormity and in-
creased arc length rom the nipple to
the IMF.
215

Part II: Problems in Augmentation Mammaplasty
216
When the patient leans orward, subtle synmastia is evident, and when the patient
leans obliquely orward, there is signi cant waviness o the attenuated so t tissue
envelope o the lower inner quadrant o the right breast.
ANALYSIS O F THE PRO BLEM
This patient had multiple breast de ormities resulting rom a series o injudiciously
per ormed surgical procedures; her problems had been exacerbated by the use o
progressively larger and larger implants. As a result o in erior overdissection o
the subpectoral pockets combined with excessively wide-based implants, she has
downward implant malposition and bilateral double-bubbles. The overly wide im-
plants also contributed to synmastia. As a result o tissue thinning and atrophy
rom the long-term presence o large implants, she had severe waviness o the right
breast, which was especially visible when she leaned orward. There were several
reasonable approaches to improving this patient’s condition. She would clearly
bene t rom smaller-volume, narrower-base–diameter implants. The double-bubble
and bottoming out could be treated with capsulorrhaphy with or without implant
pocket exchange. The use o ADM as an adjunct is worth considering and may im-
prove the patient’s chances o a long-lasting correction. But the use o ADM is by
no means mandatory, nor does it a guarantee a success ul revision. One sa e strat-
egy would be a staged approach. Because the patient had no ptosis and did not
require a mastopexy, explantation and pocket eradication could be the rst stage.
A ter a suitable waiting period, new implants could be inserted into relatively vir-
gin pockets with reliable control o the in erior and medial extent o the dissection.
However, like most women who require implant revision surgery, this patient was
motivated to achieve the best possible result in a single-stage operation.

Chapter 13 • Synmastia Repair

217
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the wide-base diameter, large-volume implants
Reattachment o the pectoral muscle to the chest wall
Correction o the bottoming out through capsulorrhaphy
Dissection o the virgin summary pocket to control the medial breast border and
correct synmastia
ADM overlay gra t to the in eromedial right breast to rein orce capsulorrhaphy
and bolster attenuated skin f ap
Insertion o narrower-base–diameter, smaller-volume, higher-projection silicone
implants
TECHNIQ UE
Corrective surgery consisted o removal o her 600 cc moderate pro le subpectoral
implants, reattachment o the pectoral muscle to the chest wall, and replacement
with 450 cc moderate plus pro le gel implants. The cut edge o the anterior capsule
was secured to the posterior capsule to reestablish the IMF at the desired level and
to correct her double-bubble de ormity. The new implants were converted to the
submammary plane to acilitate repair o synmastia and to eliminate orces gener-
ated by the pectoral muscles that might disrupt the repair. On the right side, where
the tissues were severely attenuated, a large piece o Strattice ADM was used to re-
in orce the repair.
The key operative steps are shown. The abnormally low position o the
IMF was marked on both breasts, as well as the desired level to which
the olds were to be raised; a 2 cm strip centered on the midline o the
chest was marked; this represents the area where the skin must remain
attached to the sternum to prevent synmastia. Through a new periareo-
lar incision, a virgin submammary pocket was created; the subpectoral
plane was also dissected anterior to the capsule to acilitate capsulec-
tomy. Once the anterior capsule was dissected ree rom the overlying
pectoral muscle, it was resected.

Part II: Problems in Augmentation Mammaplasty
218
When the explanted prosthesis was placed on the chest, it was obvious that the im-
plant was ar too wide to be accommodated within the base diameter o the breast.
The posterior capsule was resected to promote adherence o the pectoral muscle
to the chest wall. The pectoral muscle was secured to the chest with interrupted
nonabsorbable sutures. The desired level o the IMF was marked on the skin. The
anterior capsule was incised at the desired level o the new old. The cut edge o
the anterior capsule was secured to the chest wall with interrupted nonabsorbable
sutures.

Chapter 13 • Synmastia Repair

219
A sizer was inserted to con rm that the IMF had been raised to the desired level
and that synmastia had been adequately corrected. Identical steps were carried out
on the contralateral side. Then a large Strattice ADM gra t was readied or inser-
tion, and proper orientation o the gra t was acilitated by marionette sutures. The
Strattice gra t was positioned to rein orce the thinned-out, atrophic so t tissue enve-
lope o the in eromedial right breast. Downward compression o the implant con-
rmed that the IMF was elevated to the desired level and that the double-bubble
and bottoming out were adequately corrected.

Part II: Problems in Augmentation Mammaplasty
220
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient had an unevent ul postoperative course and achieved signi cant im-
provement o synmastia, skin waviness, and bottoming out as well as complete
resolution o her double-bubble de ormity. She is shown 10 months a ter the cor-
rective surgical procedure. With the patient standing upright, it is evident that the
double-bubble de ormity and in erior implant malposition have both been cor-
rected. When the patient leans orward, it can be seen that synmastia has been elim-
inated. When the patient leans obliquely orward, it is clear that skin waviness and
rippling have been eradicated.