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

13d Correction of Unilateral Synmastia by Conversion
of Implants From Submammary to Subpectoral
Nea l h a n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 42-year-old woman underwent bilateral augmentation mammaplasty 11 years
earlier. She had saline- lled implants in the submammary position inserted through
circumareolar incisions. The patient complained o breast asymmetry, palpability,
visibility o the medial edge o the right implant, and lateral displacement o her
right nipple.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient is a slender woman with obvious unilateral synmastia and medial mal-
position o her right implant. As a result o dislocation o the implant, the right
NAC appears laterally displaced on the breast mound, and the medial edge o the
right implant is easily palpable and visible beneath the thin, attenuated so t tissues
o the presternal area. Her breasts are rmer than desirable because o the relatively
thin layer o native breast tissue overlying the saline implants. There is no signi -
cant capsular contracture.
222

Chapter 13 • Synmastia Repair

223
ANALYSIS O F THE PRO BLEM
This patient presented with unilateral synmastia. The le t implant was in a satis ac-
tory position relative to the overlying breast, but the right implant was shi ted too
ar medially, actually crossing over the midline o the sternum. This resulted in sev-
eral undesirable characteristics: the cleavage was narrowed, the medial border o
the right implant was readily visible and easily palpable beneath the presternal so t
tissues, and the right nipple appeared laterally displaced and too close to the lateral
breast border. It was determined that the patient would bene t rom conversion o
her implants to a subpectoral pocket and replacement o her current saline implants
with smaller diameter silicone gel implants.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o both subglandular saline implants
Creation o a virgin subpectoral pocket
Secure attachment o the pectoral muscle to the overlying breast parenchyma to
eradicate the existing submammary pocket
Preservation o the medial origins o the pectoral muscle to prevent recurrent
synmastia
Insertion o a pair o smaller diameter, higher pro le silicone gel implants

Part II: Problems in Augmentation Mammaplasty
224
TECHNIQ UE
The existing saline implants were removed through the in erior hal o the patient’s
previous circumareolar incision. The implants had been inf ated to a volume o
300 cc and appeared to be moderate pro le devices. Examination o the peripros-
thetic pocket reveals that the pocket on the right side extended ar too medially and
in act crossed the midline o the sternum. The upper hal o the existing anterior
capsule on the posterior sur ace o the breast was stripped using electrocautery dis-
section. The superior posterior capsule that lined the anterior sur ace o the pec-
toral muscle was likewise stripped o , so there would be two resh tissue sur aces
to heal together. The pectoralis major muscle was then bluntly elevated rom the
chest wall. Enlargement o the subpectoral pocket medially was per ormed cau-
tiously, primarily with blunt nger dissection, to make certain the pectoral origins
remained attached to the sternum. Only the in eriormost muscle bers were divided
with the electrocautery. The pectoral muscle was then sutured, along its anterolat-
eral border, to the overlying breast parenchyma, using a series o interrupted gure-
o -eight 2-0 Prolene sutures. This eradicated the potential submammary space and
will prevent accidental “herniation” o the new implant back into the submammary
pocket. Using sizers, we decided to insert 275 cc smooth round high pro le Mentor
gel- lled implants. We thought drains were unnecessary; the incisions were closed
in layers in customary ashion.
Removal of implant
and capsule
Parenchyma
sutured
to pectoralis
major muscle
Implant placed
in subpectoral
pocket
Right nipple
displaced
Right implant
over midline

Chapter 13 • Synmastia Repair

225
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient’s appearance is shown 1 year a ter the corrective surgery. Her unilateral
synmastia has been completely alleviated. The implants are now centered beneath
the nipple and thus in the correct position relative to the overlying breast, and there
is a much thicker layer o so t tissue over the implants, which eliminates the visibil-
ity and palpability o the medial edge o the right implant. The right nipple now ap-
pears in the correct position relative to the breast mound. The use o implants with
a smaller base diameter also contributes to overall improvement, because there is
less chance that a narrower implant will extend too ar medially.

Part II: Problems in Augmentation Mammaplasty
226
TEACHING PO INTS
Synmastia is the term used to describe medial malposition o breast implants; it
can be unilateral, as in this case, or bilateral. This complication o breast augmen-
tation is usually iatrogenic and is a result o overdissection o the pocket medially.
Factors that can increase the risk o synmastia include pectus excavatum, repeated
operations with insertion o progressively larger implants, and injudicious use o
implants with an excessively wide base diameter. There may be a greater tendency
or synmastia to develop when the implant is positioned in the subpectoral plane,
because i the parasternal origins o the pectoral muscle are excessively divided, the
remaining so t tissues provide very little resistance to medial migration o the im-
plant. There are a variety o strategies that can be employed to correct synmastia.
In patients such as this woman who have submammary implants, conversion to a
subpectoral pocket is o ten success ul i care is taken to avoid dissecting the new
periprosthetic pocket too ar medially. In patients with subpectoral implants, the
converse approach o conversion to a new submammary pocket can be e ective.
When the implant is converted rom subpectoral to submammary in a patient with
synmastia, it is important to securely x the pectoral muscle to the underlying chest
wall. This immobilizes the breast and enables predictable dissection o the new sub-
mammary pocket. Capsulorrhaphy is also occasionally help ul to repair synmas-
tia, but may be technically di cult, because the tissues tend to be very attenuated.
It can be challenging to achieve secure suture xation and there is o ten puckering
o the thin skin along the medial breast border. ADMs are a use ul adjunct in many
cases and can be used to rein orce capsuloplasty and also to add thickness to the at-
tenuated, thinned-out tissues o the parasternal area.
BIBLIO GRAPHY
Becker H, Shaw KE, Kara M. Correction o symmastia using an adjustable implant. Plast Reconstr
Surg 115:2124-2126, 2005.
Codner MA, Cohen AT, Hester TR. Complications in breast augmentation: prevention and correction.
Clin Plast Surg 28:587-595, 2001.
Harley OJ, Arnstein PM. Retrocapsular pocket to correct symmastia. Plast Reconstr Surg 128:329-
331, 2011.
Selvaggi G, Giordano S, Ishak L. Synmastia: prevention and correction. Ann Plast Surg 65:455-461,
2010.
Spear SL, Bogue DP, Thomassen JM. Synmastia a ter breast augmentation. Plast Reconstr Surg 118(7
Suppl):168S-171S, 2006.

14a Conversion to a Subglandular Pocket
With a Capsular Flap
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 36-year-old woman had two previous breast augmentation operations. In her
initial procedure 3 years earlier, she underwent subglandular augmentation. Within
6 months, she developed severe capsular contractures in both breasts. To treat this
problem, her original surgeon removed the implants and repositioned them in the
submuscular space. Shortly a ter this second procedure, the patient noticed that
the le t implant had descended below her bra line, and there were indentations be-
c h a Pt e r 14
DOUBLE-BUBBLE DEFORMITY
227

Part II: Problems in Augmentation Mammaplasty
228
low the areolae parallel to and just above the IMFs. She described these as creases
across her breasts above the IMFs. The patient was happy with her overall breast
volume, but wanted her breasts to be a little larger. The size o her current implants
was unknown. She was a healthy nonsmoker with no signi cant medical issues.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
This patient demonstrates two problems related to potential overdissection in the
IMF area: severe double-bubble de ormity on her le t side and double-bubble de-
ormity with in erior displacement o the implant on her right side. These problems
are more likely to occur with submuscular placement, in which there is continued
in erior descent o the implant. The lateral view o her le t breast clearly shows the
indentation rom her original IMF, with apparent dissection well below the original
old. The double-bubble can be seen in relation to the original old position, and
signi cant in ramammary implant displacement has occurred. She has no chest wall
de ormities, and her NACs and the original IMFs appear to be symmetrical. When
she contracts her pectoralis major muscle, the le t implant elevates, whereas the
right displaces arther in eriorly. The patient has a signi cant amount o her own
breast tissue, and the breast volume is approximately hal implant and hal natural
tissue. Both o the previous procedures were per ormed through the IMF incision,
which is now excessively visible.
ANALYSIS O F THE PRO BLEM
Double-bubble de ormities are relatively common in breast augmentation patients
who have high IMFs. This woman presented with a distance o only 2 to 3 cm rom
the bottom o her areola to her IMF. The high olds may not have been as notice-
able with her original implants, because the subglandular placement pushed the
breast tissues outward and in eriorly. However, when the implants were placed in
the submuscular position and the olds were not adequately released, this problem
became magni ed and resulted in a double-bubble de ormity.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the implants
Release o the muscle rom the overlying breast parenchyma re-creates the origi-
nal subglandular pocket
Pocket site exchange, placing the implants in new subglandular pockets

Chapter 14 • Double-Bubble Deformity

229
TECHNIQ UE
The revision procedure was per ormed through an in erior periareolar incision,
which was carried down through the breast tissue to the residual anterior capsule
rom the rst procedure. The cut edges o the capsule were then mobilized or sev-
eral centimeters on each side o the dissection to acilitate later identi cation. The
dissection continued through the posterior capsule o the old subglandular pocket.
The anterior and posterior capsules o the original subglandular pocket were read-
ily identi able at this stage and were not adherent to each other. These capsules
were preserved or later use in creating the new subglandular pocket. Next, the in-
erolateral margin o the pectoralis major muscle was identi ed and divided, and
the implants were removed. Several permanent tacking sutures were placed be-
tween the deep sur ace o the pectoralis major muscle and the subpectoral posterior
capsule, thereby closing the subpectoral pocket. The subglandular posterior capsule
on the pectoralis muscle was care ully dissected. This capsule delineated the new
in erior pocket limits. Because the posterior subglandular pocket was well de ned
and adherent to the muscle, a neosubglandular pocket was created, orming the
limit o the new IMF.
The in erior dissection stopped at the original IMF to correct the double-bubble de-
ormity. Placement o the implants above the muscle helped to reduce the obvious
double-bubble crease but did not eradicate it completely. With the 375 cc moder-
ate pro le gel implants in their neosubglandular pocket, the breast tissue was reap-
proximated with sutures and the periareolar incision closed.
Residual
anterior
capsule
mobilized
Original
subglandular
pocket capsule
Implant
removed
Residual anterior
capsule reused
to form new
pocket and IMF
Pectoralis major
muscle sutured to
posterior capsule

Part II: Problems in Augmentation Mammaplasty
230
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown postoperatively in rontal, lateral, and oblique views. The
double-bubble de ormity has been corrected, and the implants are placed in a more
appropriate location. The oblique view shows a slight indentation that represents
the original IMF. It was necessary to release this area to prevent the implant rom
being too high on the patient’s chest.

Chapter 14 • Double-Bubble Deformity

231
TEACHING PO INTS
When correcting a double-bubble de ormity in a patient with a high IMF and a
constricted breast, use o the original IMF will cause the implant to be too high. In-
stead, a new IMF is created in the appropriate location. Creation o a new old o -
ten requires serial release o subglandular or submuscular tissue, depending on the
implant placement. Originally, we thought that suture xation o the lower pole o
the breast would possibly be needed to re-create a well-de ned IMF, especially on
the patient’s right side, which had more severe in erior displacement. This was not
necessary, because it was possible to create a new pocket by using the original pos-
terior capsules rom the rst subglandular augmentation. These capsules also pro-
vided adequate mechanical support.
There are several viable options or correcting in erior implant displacement and
an isolated double-bubble de ormity. Release o the constraining tissues by radical
scoring can reduce this de ormity. Alternatively, pocket site exchange is o ten one o
the best and simplest options. In this patient, a relatively simple correction was ob-
tained by placing the implants in a new subglandular space. However, capsular con-
tracture—the reason that this patient’s implants were previously moved rom the
subglandular to the submuscular plane—can recur at a later date.
BIBLIO GRAPHY
Baxter RA. Update on the split-muscle technique or breast augmentation: prevention and correction
o animation distortion and double-bubble de ormity. Aesthetic Plast Surg 35:426-429, 2011.
Khan UD. High transverse capsuloplasty or the correction o malpositioned implants ollowing aug-
mentation mammoplasty in partial submuscular plane. Aesthetic Plast Surg 36:590-599, 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.
Serra-Renom JM, Munoz-Olmo J, Serra-Mestre JM. Endoscopically assisted aesthetic augmentation
o tuberous breasts and at gra ting to correct the double bubble. Aesthetic Plast Surg 36:1114-
1119, 2012.

14b Site Change, Capsulectomy, and Conversion
to Subglandular Pockets
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 32-year-old woman presented with breast implant malposition a ter augmen-
tation mammaplasty with subpectoral saline implants. The original surgery resulted
in asymmetry and a double-bubble de ormity on the le t breast. She underwent six
subsequent procedures to correct various problems. She was 5 eet 6 inches tall and
weighed 126 pounds.
In the original procedure, the right implant was lled with 375 cc and the le t
implant with 360 cc. This resulted in a reversal o her original asymmetry (not
shown); there ore she had more saline added to the le t breast in a second proce-
dure. In a third procedure, she had the le t breast tucked up, because it had bot-
tomed out. The correction did not last, and she had another tuckup surgery (the
232

Chapter 14 • Double-Bubble Deformity

233
ourth procedure). In the th procedure, the implants were replaced with shaped
style 410 implants (Allergan, Irvine, CA), with a 375MF implant placed on the
right side and a 360MM placed on the le t side. She then had a sixth procedure to
tuck up the bottoming out that recurred on the le t side, but the implant became
medially displaced. This was corrected in a seventh procedure, whose results are
shown here. The le t breast implant has bottomed out and has a double-bubble
de ormity that is exacerbated during animation. The nipple appears to be too high
on the le t lateral view, but the problem was actually bottoming out o the implant,
causing pseudoptosis.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The subpectorally placed implant is causing a double-bubble animation de ormity
on the le t breast. Double-bubbles are more obvious when the implant has bot-
tomed out, which can occur inadvertently, especially a ter planned lowering o the
old when the implant is in the subpectoral pocket.
ANALYSIS O F THE PRO BLEM
The patient’s original procedure (and subsequent six additional procedures) were
per ormed by an accomplished and compe tent surgeon. The correction required a
di erent approach. Although the muscle can push the implant up, it only does so in
high-breasted patients. The pectoralis muscle can actually push the implant down,
particularly when it has already started to bottom out. Placement o the implant
in a subglandular pocket can correct this problem. When the implant is placed in a
subpectoral pocket, the ree edge o the muscle attaches to the capsule as it devel-
ops. This leads to a double-bubble de ormity with animation.
RECOMMENDED SOLUTION TO THE PROBLEM
Do something di erent!
Bilateral pocket exchange in which the same implants are moved rom subpecto-
ral to subglandular pockets
Capsulorrhaphy on the le t side
TECHNIQ UE
The patient had a bilateral pocket exchange procedure. The implants were moved
rom subpectoral pockets to subglandular pockets. The capsule on the le t side was
elevated rom the chest wall, and a capsulorrhaphy was per ormed.

Part II: Problems in Augmentation Mammaplasty
234
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 3 years a ter the correction. The le t IMF is elevated and
the nipple no longer appears to be too high, because the breast mound has been
changed to t the existing nipple position.

Chapter 14 • Double-Bubble Deformity

235
It is important in any breast procedure to evaluate the ootprint, the breast mound,
and the nipple position. Surgeons need to know what changes can be made to these
eatures. This requires an understanding o the dynamics that were involved in cre-
ating the problem. In this case, the subpectoral pocket was an aggravating actor,
and a site change was necessary or correction.
TEACHING PO INTS
The subpectoral location can be ideal in patients with minimal subcutaneous tissue
or breast tissue to obstruct the visibility o the implant edges. Un ortunately, a sub-
pectoral pocket can contribute both to the double-bubble e ect and to bottoming
out o the implant. In this patient, repeat capsulorrhaphies had been unsuccess ully
attempted and a new approach was needed. A site change rom the subpectoral
pocket to a subglandular pocket provided a long-lasting result.
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. 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.

14c Site Change to Subglandular Pockets
With Mastopexy
el iz a bet h J. h a l l -Fin d l ay
PATIENT HISTO RY LEADING TO SPECIFIC BREAST PRO BLEM
This 31-year-old woman underwent a bilateral breast augmentation with smooth
walled silicone gel MPP 350 cc implants (Mentor, Santa Barbara, CA) placed sub-
pectorally through an in ramammary incision. She was 5 eet 4 inches tall, weighed
110 pounds, and wore a size 34A bra. She had wide cleavage and slight breast pto-
sis. A wider-base implant was placed to help ll the medial aspect o the breast be-
low the insertion o the pectoralis muscle. The patient developed a double-bubble
de ormity, which was exacerbated by her mild ptosis and worsened with muscle
movement.
236

Chapter 14 • Double-Bubble Deformity

237
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
A double-bubble de ormity can be di cult to correct. It can be caused by three
problems, all o which are evident in this patient:

1. Inadequate release and resultant tightening o the IMF

2. Breast glandular ptosis with a water all e ect o breast tissue dropping o
the implant

3. Muscle adhesions where the dual plane release was per ormed
ANALYSIS O F THE PRO BLEM
It was thought that the old de ormity and glandular ptosis could be corrected by
per orming a mastopexy. Release o the muscle could help to correct its contribu-
tion to the double-bubble animation de ormity.
A superior pedicle vertical mastopexy was planned, along with release o the mus-
cle attachments.
The patient is shown 4 weeks a ter surgery. She has an overcorrected shape, which
is common at this early postoperative stage.

Part II: Problems in Augmentation Mammaplasty
238
She is shown 5 months later with some settling o the shape but with persistent ani-
mation de ormity o both breasts.
Eleven months a ter the mastopexy, and almost 2 years a ter the original procedure,
the animation de ormity persists. The nipples may have been placed too high on the
breast. Correction was attempted by elevation o the implants in a neosubpectoral
pocket and release o the muscle to correct the de ormity.
Two months a ter the attempted correction, her breasts looked worse.

Chapter 14 • Double-Bubble Deformity

239
She then underwent a ourth operation, in which the implants were moved to a
subglandular pocket and scars were revised.
She is shown 8 months a ter the revision, with some residual de ormity and asym-
metry. The le t implant is so t but too high. The double-bubble de ormity is cor-
rected. The right upper pole looks good, without edge visibility in the subglandular
pocket. A revision to release the le t breast capsule was per ormed to allow the im-
plant to sit in a slightly lower pocket.
RECOMMENDED SOLUTION TO THE PROBLEM
Pocket exchange rom subpectoral to subglandular position
TECHNIQ UE
This series shows how important (and di cult) it is to accurately diagnosis the
problem. The shape was improved by per orming a mastopexy, which corrected
the glandular ptosis and nipple and areolar position. Un ortunately, release o both
the IMF constriction and muscle adhesions was not enough. The muscle adhesions
recurred. The muscle’s contribution to the double-bubble de ormity was corrected
with placement o the implant in a subglandular pocket.

Part II: Problems in Augmentation Mammaplasty
240
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
She is shown 2 months a ter the pocket exchange to the subglandular position.
Compared with other preoperative views over the course o this patient’s treatment,
the shape was signi cantly improved, but her le t breast required a urther correc-
tion—capsular release. Fortunately, this patient has been very tolerant throughout
this whole process. Revision procedures are covered in our particular provincial
health care system. Obviously, many other surgeons do not have this advantage.
Hope ully, other surgeons can prevent this problem by learning rom my example.
After augmentation,
showing double-bubble deformity
After superior pedicle vertical
mastopexy
After attempted correction with
neosubpectoral pocket
After movement of implant to subglandular
pocket and scar revision
After release of left breast capsule

Chapter 14 • Double-Bubble Deformity

241
TEACHING PO INTS
The breast shape that this patient had at presentation probably required a masto-
pexy or correction. The shape o a patient’s breasts at presentation determines the
shape that results a ter augmentation alone is per ormed. This patient had a pro-
truding NAC with a constricted IMF. In retrospect, a mastopexy would have been a
better choice.
A double-bubble de ormity can be di cult to correct with a muscle release. Some-
times the best way to treat (and prevent) it is to place the implant in a subglandular
pocket i possible.
BIBLIO GRAPHY
Fisher J. Breast augmentation using silicone gel- lled implants. Aesthet Surg J 27:551-557, 2007.
Massiha H. Augmentation in ptotic and densely glandular breasts: prevention, treatment and classi -
cation o double-bubble de ormity. Ann Plast Surg 44:143-146, 2000.
Medard de Chardon V, Balaguer T, Chignon-Sicard B, et al. Double breast contour in primary aes-
thetic breast augmentation, incidence, prevention and treatment. Ann Plast Surg 64:390-396,
2010.
Puckett CL, Croll GH, Reichel CA, et al. A critical look at capsule contracture in subglandular versus
subpectoral mammary augmentation. Aesthetic Plast Surg 11:23-28, 1987.
Tebbetts JB. Dual plane breast augmentation: optimizing implant so t-tissue relationships in a wide
range o breast types. Plast Reconstr Surg 107:1255-1272, 2001.

14d Capsuloplasty and Implant Conversion
to Submammary Pocket
n ea l h a n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 38-year-old woman was re erred or correction o a double-bubble de ormity
a ter augmentation. She had given birth to twins 9 years previously; as a result o
prolonged breast- eeding, her breasts “def ated.” A local plastic surgeon per ormed
bilateral subpectoral augmentation through in ramammary incisions. Allergan
Natrelle implants were inserted (a 375 cc implant on the right side and a 325 cc
implant on the le t side). The patient stated that immediately a ter surgery her
breasts “looked good,” but as the swelling subsided, the double-bubble de ormity
appeared. Her operating surgeon reassured her that it would get better over time.
However, she did not see improvement and decided to seek a second opinion. In ad-
dition to the obvious de ormity, she was bothered by her scars because they were
very conspicuous. She had expected the scars to be hidden in the breast crease, but
they were readily visible on the anterior sur ace o the in erior poles.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient is a t woman who has had bilateral augmentation mammaplasty. Her
breasts have a very peculiar, abnormal appearance because o a bilateral double-
bubble de ormity. When she f exes her pectoral muscles, the de ormity is greatly
accentuated.
242

Chapter 14 • Double-Bubble Deformity

243
The in ramammary incisions are erythematous and quite conspicuous, because they
lie on the anterior breast sur ace. Her breasts are so t (Baker grade I), and she is
happy with their size.
ANALYSIS O F THE PRO BLEM
This patient presented with the classic mani estations o the double-bubble de or-
mity. Patients with this anomaly have two parallel olds beneath the breast. The
superiormost old represents the native or original IMF, whereas the lower old
indicates the level to which the pocket has been dissected or to which the implant
has spontaneously descended. The upper old may so ten to some degree over time.
This can be acilitated by massaging the breast and wearing a circum erential elas-
tic band around the upper pole. However, patients with signi cant double-bubble
de ormity usually require surgical intervention to achieve satis actory correction.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the subpectoral silicone implants
Reattachment o the pectoral muscle to the chest wall
In erior capsuloplasty to close the pockets
Reinsertion o the same implants into the new submammary pockets

Part II: Problems in Augmentation Mammaplasty
244
TECHNIQ UE
With the patient in the supine position on the operating table, the midline o the
sternum and the proposed medial borders o the breasts (1 cm lateral to the midline
on each side) were marked. The subpectoral implants were removed through the
existing scars. The lateral border o the pectoralis major muscle was grasped, and
the muscle was dissected away rom the overlying breast parenchyma to create a
new submammary pocket.
The undersur ace o the pectoral muscle (anterior capsule) was roughened with
electrocautery to create a raw tissue sur ace; likewise, the posterior capsule was
stripped o the chest wall to create a resh tissue sur ace to promote adhesion o
the muscle to the chest wall. A 10 Fr round Jackson-Pratt drain was placed beneath
the pectoral muscle. The muscle and chest were approximated and sutured in place
with interrupted gure-o -eight sutures o 2-0 Prolene. The planned excision or the
capsulorrhaphy was marked. The superior border o the scar tissue crescent to be
resected was placed at the desired level o the IMF.

Chapter 14 • Double-Bubble Deformity

245
The crescent o scar tissue capsule was then resected. The two raw tissue sur aces
were approximated, and the de ect was sutured with a running continuous locked
0 Prolene suture. The implant that was removed at the beginning o the case had
been soaked in dilute Betadine solution and was now ready or insertion. It was
care ully positioned in the new submammary pocket, and the incision was closed in
layers. Identical steps were carried out on the other side.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 1 year a ter corrective surgery. She had an unremarkable post-
operative recovery and achieved an excellent result.

Part II: Problems in Augmentation Mammaplasty
246
The double-bubble de ormity is completely corrected. Her breasts appear normal
both at rest and with pectoral muscle contraction. There is no residual crease on
the in erior pole o either breast, and the scars are well camouf aged in the IMF bi-
laterally.

Chapter 14 • Double-Bubble Deformity

247
TEACHING PO INTS
The double-bubble de ormity typically mani ests as a constriction or band that
extends transversely across the in erior hal o the augmented breast. It most re-
quently develops in patients who have a tight or constricted IMF or a short dis-
tance rom the nipple to the old, and in those with tuberous breast de ormity. In
these cases the de ormity is caused by ailure o the native IMF to recontour over
the lower pole o the implant. In patients with these predisposing morphologic vari-
ations, it is critical to ully release the ligamentous attachments (between the pec-
toral ascia and the undersur ace o the dermis) that contribute to ormation o the
in ramammary crease.
A double-bubble may arise, however, in patients without predisposing actors (as
in this case). In such instances the pocket typically has been overdissected, and the
in erior pole o the implant extends beneath the breast into the upper abdominal
tissues. This problem can be treated by recon guration o the pocket so that it lies
in correct anatomic relation to the breast. This can be accomplished by judicious
capsulorrhaphy. I the implant is in the subpectoral plane (as in this case), tranposi-
tioning it into a new submammary pocket has several advantages. It allows greater
control in con guration o the new pocket; it completely releases residual attach-
ments o the pectoral ascia to the IMF (in cases that require lowering o the old);
and it eliminates the downward and lateral orce that the pectoral muscle may ex-
ert on the implant. Elimination o this orce vector helps to ensure the integrity o
the capsulorrhaphy repair and reduces the risk o recurrence o the double-bubble
de ormity.
BIBLIO GRAPHY
Bayati S, Seckel BR. In ramammary crease ligament. Plast Reconstr Surg 95:501-508, 1995.
Handel N. Managing complications o augmentation mammaplasty. In Spear SL, ed. Surgery o the
Breast: Principles and Art, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2011.
Hidalgo DA. Breast augmentation: choosing the optimal incision, implant, and pocket plane. Plast Re-
constr Surg 105:2202-2216, 2000.
Muntan CD, Sundine MJ, Rink RD, et al. In ramammary old: a histologic reappraisal. Plast Reconstr
Surg 105:549-556, 2000.

14e Radial Capsular Scoring With Insertion
of Wider-Base Implants
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This woman presented 12 years a ter subglandular augmentation. Her major com-
plaint was a double-bubble de ormity along the medial aspect o both breasts, with
a wide intermammary separation. She wished to have slightly larger implants, but
her major concern was the double-bubble old medially.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The most obvious component to the patient’s de ormity is what appears to be a
double-bubble medially on both breasts. The patient was asked to contract her pec-
toral muscles to ensure that the implants were not placed submuscularly. These
muscles did not move with contraction, con rming their subglandular placement.
Both breasts had Baker II capsules. Bottoming out was slightly worse on the le t
breast. Breast tissue is adequate or coverage o the implant in the subglandular
plane. There are no chest wall abnormalities, and the breast volume appears sym-
metrical.
248

Chapter 14 • Double-Bubble Deformity

249
ANALYSIS O F THE PRO BLEM
These implants appeared to be placed in the subglandular position; there ore the
double-bubble de ormity was most likely created by overdissection medially be-
low the IMF. This also may have contributed to bottoming out o the le t breast.
Although preoperative photos were not available, this patient likely had high, tight
olds preoperatively, with a wide interbreast distance.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the original subglandular implants
Radial scoring o the breast and subcutaneous tissue along the medial aspect o
both breasts
Replacement o the 250 cc implants with wider-base 325 cc gel implants
TECHNIQ UE
Bilateral in erior periareolar incisions were made through the breast tissue and
Baker II capsules. Although the patient had IMF incisions, we thought that ap-
proach rom above would allow better access and correction o the double-bubble
de ormity. The implants were intact with no markings and measured approximately
250 cc via water displacement. The subglandular capsule medially had an indenta-
tion parallel to the external double-bubble de ormity.
Periareolar incision
Radial scoring
New
implant
Original
implant
Increased base width of implant

Part II: Problems in Augmentation Mammaplasty
250
In the rst step, electrocautery and a lighted retractor were used to make cuts at
a right angle through the capsule along the indented site. This was done on both
sides, allowing the medial breast tissue to expand. The breast tissue in this area was
urther divided through the capsule incision to acilitate more expansion. Once he-
mostasis was su cient, temporary sizers were inserted to assess the correction o
the double-bubble de ormity. The next step consisted o expanding the base diam-
eter o the subglandular pocket by dissecting both medially and laterally.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
Postoperatively the double-bubble de ormity is completely corrected, and the pa-
tient’s NACs are better positioned. The base diameter o her implants is more ap-
propriate. A problem that might have appeared to be complex was solved with two
simple solutions: (1) radial scoring to release both the capsule and breast tissue
medially, and (2) insertion o an implant with a wider-base diameter that lled the
space medially.

Chapter 14 • Double-Bubble Deformity

251
In reviewing the patient’s original photos, it is evident that i a wider-base implant
had been used in the original surgery, the double-bubble irregularity may not have
been as visible because greater pressure would have been applied to the tissue in
this area. The wider base diameter and the increased volume above the NACs have
improved the nipple position by rotating the NACs in eriorly. Postoperatively it ap-
pears that the IMF may have been adjusted; however, nothing was done to the old
during this second procedure. This improvement is solely the result o a wider base
and larger implant lling the upper pole o the breast mound.
TEACHING PO INTS
I patients have high, tight olds preoperatively, proper release is necessary. Place-
ment o an implant o the appropriate base diameter can reduce medial de ormity
such as a double-bubble by adequately compressing the medial tissue. An increased
implant size can create the appearance o improved nipple position, because greater
superior ullness causes the nipples to rotate in eriorly.

Part II: Problems in Augmentation Mammaplasty
252
BIBLIO GRAPHY
Baxter RA. Update on the split-muscle technique or breast augmentation: prevention and correction
o animation distortion and double-bubble de ormity. Aesthetic Plast Surg 35:426-429, 2011.
Khan UD. High transverse capsuloplasty or the correction o malpositioned implants ollowing aug-
mentation mammoplasty in partial submuscular plane. Aesthetic Plast Surg 36:590-599, 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.
Serra-Renom JM, Munoz-Olmo J, Serra-Mestre JM. Endoscopically assisted aesthetic augmentation
o tuberous breasts and at gra ting to correct the double bubble. Aesthetic Plast Surg 36:1114-
1119, 2012.

C h a p t e r 15
UPPER POLE DEFICIENCY OR
CONTOUR DEFORMITY
15a Fat Gra ting to Treat Wrinkling and Contour De ormity
Mo u st a ph a h a md i
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 37-year-old patient had had submuscular gel implant breast augmentation
per ormed 2 years previously at a di erent acility. She presented to our clinic be-
cause o an unsatis actory result. She complained about the palpable edges o her
implant, and asked that the appearance o her cleavage be improved. She had lost
55 pounds and then underwent body-contouring surgery with breast augmentation
at a subsequent time. She was a nonsmoker who had no previous pregnancies.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
Clinical examination shows good symmetry, with Baker grade II capsular contrac-
ture. The edges o the implants are palpable medially, and there is visible rippling
along the lateral aspect o the le t breast. The quality o the skin is average with
light stretch marks.
253

Part II: Problems in Augmentation Mammaplasty
254
ANALYSIS O F THE PRO BLEM
A larger implant was not a good option or this patient because she lacked enough
tissue or adequate coverage. Another possible approach was a combined periare-
olar mastopexy with implant exchange to smaller implants; however, the patient
wanted to maintain her current breast volume.
RECOMMENDED SOLUTION TO THE PROBLEM
It was ultimately decided to use at gra ting to cover the edge o the implant and to
improve the cleavage area:
Combined intercostal nerve bloc with local anesthesia
Fat harvesting with a small-hole cannula under moderate negative pressure
Pushing the implant away rom the injection zone
Avoiding transcapsular injection
Multidirectional/multilayer injection technique using a blunt cannula
Consideration o 10% overcorrection
Advising the patient to avoid wearing a bra and placing any pressure on the
injected areas or 7 days.
TECHNIQ UE
The procedure was per ormed with local anesthesia. An intercostal nerve block was
used or the recipient area, and the periumbilical donor site was in ltrated with
1% lidocaine and 1:100,000 epinephrine in Ringer’s lactate solution. Fat was har-
vested using a two-holed blunt cannula, 3 mm in inner diameter, connected to a
10 cc syringe. The at was centri uged or 2 minutes at 3000 rpm. The oil layer was
decanted and the aqueous raction drained. The at was then trans erred to 3 cc
Luer-Lok syringes. The incisions were positioned to allow at injection rom at least
two di erent directions. Four incisions were used to reach the lateral and medial
sides o the breast. Two incisions were made at the edge o the areola, and two in-
cisions were placed at the periphery o the breast in the axillary region and in the
IMF.
Through a 1 mm incision, the at gra ts
were injected by a blunt 17-gauge
Coleman cannula in a retrograde ash-
ion. Less than 1 cc was placed with
each withdrawal o the cannula.

Chapter 15 • Upper Pole Deficiency or Contour Deformity

255
A total o 21 and 16 cc at was placed over the le t and right medial sides o the
cleavage area, respectively. Over the lateral le t side, 17 cc o at was placed. The at
was injected under the skin and above the capsule. No stitches were used to close
the skin incision. Both breasts were then supported with a light Micro oam dress-
ing or the rst 7 days postoperatively. Moderate bruising was observed during
the rst 10 postoperative days. A surgical bra without compression was used or
4 weeks.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient’s immediate results are shown.
17 cc
21 cc
16 cc
Areas of fat grafting

Part II: Problems in Augmentation Mammaplasty
256
At 1 year postoperatively, she noticed improvement not only in the quality o the
skin but also in the breast as a whole. At the 2-year ollow-up, the rippling had dis-
appeared completely and the edges o the implant were no longer palpable. The in-
termammary area improved the most, and the patient now had attractive cleavage.

Chapter 15 • Upper Pole Deficiency or Contour Deformity

257
TEACHING PO INTS
Recent developments and re nements o the at gra ting technique have made it
possible to decrease the amount o at necrosis a ter autologous at transplantation
or so t tissue augmentation. Coleman advocated structural at gra ting or so t tis-
sue rejuvenation o the ace and hand, noting signi cant improvement in appear-
ance. More recently, Coleman and Soboeiro reported their clinical experience o
at injection to the breast with encouraging results. Autologous at gra ting to the
breast has gained much attention recently in the plastic surgery community. How-
ever, the e cacy and long-term complications o such a procedure or cosmetic
breast enhancement have still not been determined in a large series o patients.
Technically speaking, there are a number o points to consider:

Ô The e ect o the harvesting cannula diameter on at gra t viability was
examined in a ew studies. Aspiration o at was per ormed using blunt
Accelerator-type 2, 3, and 4 mm aspiration cannulas with one hole proxi-
mally. This comparative in vitro test viability study concluded in avor o
larger diameter cannulas.

Ô There is a consensus on the importance o using low negative pressure dur-
ing the harvesting procedure, whether with a liposuction device or a syringe.
Normal liposuction at 2 760 mm Hg or 2 1 atm negative pressure seems
detrimental or gra t viability and should not be used in lipotrans er proce-
dures.

Ô The lipostructure technique described by Coleman consists o an atraumatic
method o at harvesting, centri ugation, and microreinjection to preserve
the ragile donor tissue. Depositing small particles adjacent to vascularized
host structures enables nutrition through di usion. A higher ratio o sur ace
area/volume promotes better di usion. It is estimated that tissue ragments
1.5 mm in diameter can survive this way. In general, the delay period or re-
vascularization o the gra t is 3 to 4 days.

Ô Imaging abnormalities such as liponecrotic cysts and calci cations a ter au-
tologous at transplantation have not been well documented in the literature
except or a ew early case series. Cysts and calci cations in the subcutane-
ous and subglandular tissues where the at gra ts were placed can be di er-
entiated rom benign or malignant lesions within the glandular tissue. A ter
at gra ting, ultrasonography appears to be superior to mammography in
di erentiating a cyst rom a solid mass o the breast.

Ô Fat gra ting can enhance the aesthetic results a ter breast augmentation.

Ô Gentle handling o the at gra t is essential or the success o the procedure.

Ô Cannulas o 3 to 4 mm in diameter with multiple holes can sa ely be used
or harvesting the at.

Ô A small cannula (1 mm or less) should be used to inject at.

Ô The injected at should be placed in small aliquots rather than large deposits.

Ô Always use two incisions to allow di erent injection directions.

Ô Consider 10% overcorrection.

Part II: Problems in Augmentation Mammaplasty
258
BIBLIO GRAPHY
Coleman SR, Saboeiro AP. Fat gra ting to the breast revisited: sa ety and e cacy. Plast Reconstr Surg
119:775-785, 2007.
Delay E, Garson S, Tousson G, Sinna R. Fat injection to the breast: technique, results, and indications
based on 880 procedures over 10 years. Aesthet Surg J 29:360-376, 2009.
Gonzalez AM, Lobocki C, Kelly CP, Jackson IT. An alternative method or harvest and processing at
gra ts: an in vitro study o cell viability and survival. Plast Reconstr Surg 120:285-294, 2007.
Khouri R, Del Vecchio D. Breast reconstruction and augmentation using pre-expansion and autolo-
gous at transplantation. Clin Plast Surg 36:269-280, 2009.
Mojallal A, Auxen ans C, Lequeux C, et al. Inf uence o negative pressure when harvesting adipose tis-
sue on cell yield o the stromal-vascular raction. Biomed Mater Eng 18:193-197, 2008.
Oszoy Z, Kul Z, Bilir A. The role o cannula diameter in improved adipocyte viability: a quantitative
analysis. Aesthet Surg J 26:287-289, 2006.
Pu LL, Cui X, Fink BF, et al. The viability o atty tissues within adipose aspirates a ter conventional
liposuction: a comprehensive study. Ann Plast Surg 54:288-292, 2005.
Rohrich RJ, Sorokin ES, Brown SA. In search o improved at trans er viability: a quantitative analysis
o the role o centri ugation and harvest site. Plast Reconstr Surg 113:391-395, 2004.

15b Anatomic Implants or Upper Pole Def ciency
Br ia n d . pet er so n
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 22-year-old nulliparous patient had an upper pole breast de ormity rom the
use o round subglandular implants that were corrected by using anatomic-shaped
textured cohesive gel implants. She initially requested an increase rom a C to D
cup. Smooth wall 400 cc saline implants were initially placed in a subglandular po-
sition; a subsequent increase to 800 cc implants was per ormed because o the pa-
tient’s dissatis action with the initial size enhancement.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
Bilateral upper pole contour irregularities are apparent as a result o the transverse
diameter on the large implants, plane o placement, and limited upper pole so t tis-
sue coverage.
ANALYSIS O F THE PRO BLEM
This case exempli es upper pole de ormity o the breast when large round implants
are used, particularly in a subglandular position. Because o the patient’s desire or
large breasts, necessitating the use o large implants, the solution was to change the
implant to a 740 cc ull height/ ull projection shaped anatomic style that would
acilitate less upper pole volume. With limited upper pole so t tissue coverage, sub-
muscular placement would provide an additional layer or a smoother transition in
the upper pole. The textured sur ace allows tissue integration and adherence to pre-
vent later implant migration in eriorly or laterally.
259

Part II: Problems in Augmentation Mammaplasty
260
RECOMMENDED SOLUTION TO THE PROBLEM
Implant exchange using a 740 cc ull height/ ull projection shaped anatomic
style
Change to submuscular placement
TECHNIQ UE
Using the previous incision in the IMF, the saline implants were removed. The cap-
sule on the anterior sur ace o the pectoralis muscle was removed to allow muscle
expansion with the new submuscular positioning o the textured anatomic im-
plants. The anterior capsule on the undersur ace o the breast was divided trans-
versely at the height o the nipple. The lower established capsule was maintained to
provide support or the implant. A ter the submuscular pocket was dissected, the
in erior border o the muscle was sutured to the lower anterior capsulotomy to pre-
vent window-shading o the muscle upward, to support the implant, and to isolate
the subglandular pocket. In this case, an anatomic implant was chosen to diminish
the upper pole ullness that is o ten associated with a large round implant, to pro-
mote tissue adherence, and to maintain implant position.
Subglandularly
placed round
implant
Submuscularly
placed anatomic-
shaped implant

Chapter 15 • Upper Pole Deficiency or Contour Deformity

261
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The postoperative photos were taken 4 years a ter the revision surgery. Despite
the use o large anatomic implants, the upper pole de ormity has largely been cor-
rected, with overall improved breast shape and contour in all views.
The textured sur ace has allowed tissue integration and helped to maintain implant
position despite the size and obligate weight o the implant.
The rm consistency o the textured cohesive implant produces a more rigid breast,
which is o ten more acceptable than the mobile round smooth wall implant that is
prone to producing more palpable and o ten visible ripple de ormities.

Part II: Problems in Augmentation Mammaplasty
262
TEACHING PO INTS
Initial understanding o the patient’s nal expectations and appearance is o ten di -
cult to determine in advance. The use o photographs o the patient’s eventual ap-
pearance would have been use ul to comprehend what her expected nal outcome
would look like.
The use o shaped cohesive gel anatomic implants provides a smooth transition in
the upper pole o the breast, especially with large implants in a submuscular posi-
tion. The cohesive sur ace acilitates tissue adherence to prevent implant rotation in
most cases.
Smaller round implants do not lead to similar upper pole de ormity issues because
o the decreased transverse diameter; there ore they are acceptable, particularly in a
submuscular location. Avoiding the use o large implants will help to eliminate up-
per pole contour irregularities.
BIBLIO GRAPHY
Adams WP Jr. Capsular contracture: what is it? What causes it? How can it be prevented and man-
aged? Clin Plast Surg 36:119-126, 2009.
Bengston BP, Van Natta BW, Murphy DK, et al; Style 410 U.S. Core Clinical Study Group. Style
410 highly cohesive silicone breast implant core study results at 3 years. Plast Reconstr Surg
120(7 suppl 1):40S-48S, 2007.
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.
Hedén P, Jernbeck J, Hober M. Breast augmentation with anatomical cohesive gel implants: the
world’s largest current experience. Clin Plast Surg 28:531-552, 2001.
Niechajev I. Mammary augmentation by cohesive silicone gel implants with anatomic shape: technical
considerations. Aesthetic Plast Surg 25:397-403, 2001.
Peters W. Current status o breast implant survival properties and the management o the woman with
silicone gel breast implants. Can J Plast Surg 8:54-67, 2000.
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.

15c High Prof le Silicone Gel Implants or Correction
o Rippling
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This patient was initially seen or breast augmentation when she was 42 years old.
Her primary complaints were the absence o breast tissue and the inability to wear
many types o clothing or other attire. At that time she requested saline implants
and stated that she hoped her breasts could be at least a ull B or possibly a small
C cup. At the initial consultation it was explained that placing the implants under
the muscle would result in palpable wrinkles and olds. Complying with the pa-
tient’s wishes, 275 cc moderate pro le textured saline implants lled to 300 cc were
placed in subpectoral pockets. Within 2 months a ter the procedure, the patient
complained o signi cant problems associated with implant wrinkling. This prob-
lem was most noticeable in the superior pole o her breasts, especially when she
leaned orward slightly, even with submuscular placement and slight over lling o
the implants. The patient requested resolution o the problem and agreed to the use
o gel implants.
263

Part II: Problems in Augmentation Mammaplasty
264
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
This patient essentially has no body at and very minimal breast tissue. She also has
a very prominent sternum and an in erior IMF that rapidly tapers o along the me-
dial extension. Her upper ribs are very prominent because o the lack o so t tissue.
The minimal breast tissue she has is widely separated centrally, and the de ormity
is urther exaggerated by pectus excavatum o the lower portion o the sternum.
There is minimal asymmetry, with slightly more breast tissue on the right than on
the le t. Another important component o this patient’s anatomy is that when she
contracts her pectoralis muscle, the medial attachment can be identi ed at a signi -
cant distance rom the midline. When the patient was seen 2 months a ter the in-
sertion o the saline subpectoral implants, it was obvious that the original concerns
regarding wrinkling and palpable irregularities were justi ed.
ANALYSIS O F THE PRO BLEM
No matter what technique or implant is used, it is di cult to obtain an ideal result
in this type o patient. Even with subpectoral pockets, the risk o rippling or olds
is extremely high. In this case the act that the patient wanted saline implants in-
creased the probability that problems would occur. It was explained to the patient
that slightly over lling the saline implants might reduce some o these potential
problems, but there were no guarantees. In act, signi cantly over lling a saline
implant can actually increase problems with visible olds by causing scalloping o
the implant shell. Finally, it was determined that it was best to limit the base diam-
eter and implant size in this patient because o her chest wall and so t tissue charac-
teristics.
Only 2 months a ter the insertion o the saline subpectoral implants, it was obvious
that all o the concerns with using this type o implant in this patient were realized.
The situation then became how to correct her problem. The patient agreed to what
should have been done in the rst place: replacement o the saline implants with
smooth wall high pro le silicone gel implants.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o textured saline implants
Replacement with smooth wall high pro le gel implants

Chapter 15 • Upper Pole Deficiency or Contour Deformity

265
TECHNIQ UE
The same submuscular pockets that were created or the saline implants were used
or the smooth wall pro le gel implants. The medial extent o the pockets was
slightly extended to reduce the central breast separation. In the original opera-
tion there was a more conservative medial submuscular dissection because o the
use o saline implants. In converting to gel implants, we decided it was appropriate
to slightly widen the base diameter o the pocket dissection. A ter meticulous he-
mostasis and irrigation, the original 275 cc textured saline implants that had been
lled to 300 cc were replaced with 325 cc smooth wall high pro le gel implants.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The postoperative photos show complete resolution o the rippling and wrinkling
problem as well as improved overall contour o the breasts. There are no irregulari-
ties in the superior pole o the breast, as there were with the saline implants. In ad-
dition, by urther medial submuscular dissection, there is less o a gap between the
breasts. Although extending the medial submuscular dissection was success ul, this
had to be done care ully, because synmastia is a potential complication in this type
o patient.
TEACHING PO INTS
Textured saline implants, even when placed submuscularly, can be a poor choice
o implant in this type o patient; thus converting to a high pro le gel implant is a
good solution. Today some plastic surgeons would consider at injections to the tis-
sue overlying the implant to correct implant de ormities, but this patient had very
little donor at available, so at injections were not an option.

Part II: Problems in Augmentation Mammaplasty
266
BIBLIO GRAPHY
Araco A, Gravante G, Araco F, et al. A retrospective analysis o 3,000 primary aesthetic breast aug-
mentations: postoperative complications and associated actors. Aesthetic Plast Surg 31:532-539,
2007.
Basile FV, Basile AR. Reoperative transaxillary breast surgery: using the axillary incision to treat aug-
mentation-related complications. Aesthetic Plast Surg 36:323-330, 2012.
Lee JH, Lee PK, Oh DY, et al. Subpectoral-sub ascial breast augmentation or thin-skinned patients.
Aesthetic Plast Surg 36:115-121, 2012.
Maxwell GP, Birchenough SA, Gabriel A. E cacy o neopectoral pocket in revisionary breast surgery.
Aesthet Surg J 29:379-385, 2009.
McGregor JC, Bahia H. A possible new way o managing breast implant rippling using an autogenous
ascia lata patch. Br J Plast Surg 57:372-374, 2004.
Riggio E. Breast augmentation with extra-projected and high-cohesive Dual-Gel Prosthesis 510: a pro-
spective study o 75 consecutive cases or a new method (the Zenith system). Aesthetic Plast Surg
36:866-878, 2012.

16a ADM and Eccentric Periareolar Mastopexy
Nea l Ha n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 33-year-old woman had her initial breast augmentation at age 21, with sub-
pectoral saline implants inserted though a periareolar incision. The patient recalled
that the implants were about 325 cc in volume and described her result as “good.”
She subsequently became pregnant and breast- ed her baby or 18 months. A ter-
ward she noted ptosis and increased rmness o both breasts; she then underwent a
revision consisting o implant removal and replacement, again with saline- lled im-
plants. The patient developed signi cant capsular contracture on the le t side within
a year, which necessitated yet another revision, her third operation. At that proce-
dure, she had a capsulectomy and her implants were replaced with larger, 525 cc
saline implants. Within months the patient noted implant malposition, with the le t
implant dropping “too low” and increasing rmness o the right breast; the patient
also complained that her periareolar scars were indented and her nipples asymmet-
rical.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient, o mixed Polynesian and
Asian ancestry, has presented 1 year
a ter her third operation.
267
c H a Pt e r 16
INFERIOR POLE STRETCH
DEFORMITY

Part II: Problems in Augmentation Mammaplasty
268
She has marked bilateral capsular contracture that is right side Baker grade IV, le t
side Baker grade III. Her breasts are asymmetrical, with the le t breast appearing
lower than the right breast and the le t nipple looking higher than the right nipple.
Measurements reveal that the distance rom the sternal notch to the top 12 o’clock
position o the areola is 18 cm on the right and 17 cm the le t side. The IMFs are at
the same level. Care ul inspection o the NACs reveals that on the right side there
is a depressed, curvilinear scar running transversely across the lower hal o the
areola, midway between the nipple and areolar border rather than directly at the
areolar border. The scar is retracted and tethered to deeper structures. On the le t

Chapter 16 • Inferior Pole Stretch Deformity

269
side there is a transareolar scar running horizontally across the areola and passing
just beneath the nipple. The le t NAC is distorted, with the nipple displaced superi-
orly. There is scarring and depigmentation o the skin adjacent to the lower border
o the areola. The skin and so t tissue o the lower pole o the le t breast are attenu-
ated and stretched out; a pinch test reveals that the so t tissue envelope in this area
is no more than 2 to 3 mm thick. The skin o the lower hal o the le t breast has
been stretched, causing the distance rom the border o the areola to the IMF on the
le t side to be 1.5 cm greater than that on the right side.
The disparity in position o the lower poles o the breasts is not rom bottoming
out but rather rom in erior pole stretch de ormity. This is most evident when the
lateral views o the two breasts are compared. The patient wishes to have as many
o these abnormalities as possible corrected in a single-stage procedure.
ANALYSIS O F THE PRO BLEM
This patient, who had undergone augmentation mammaplasty and two subsequent
revisions, presented with a constellation o abnormalities. She has bilateral capsu-
lar contracture, unsatis actory scarring, distortion o the NACs, and asymmetrical
breasts. It may appear at rst that she has bottoming out o her le t implant, there-
ore in erior malposition. But on care ul inspection, the IMFs are at almost the ex-
act same level on both sides. The le t breast looks lower because the so t tissues o
the in erior pole o the breast have stretched out. This condition, known as inferior
pole stretch deformity, needs to be distinguished rom implant malposition with
in erior displacement o the IMF. The key to correcting in erior pole stretch de or-
mity is to modi y the so t tissue envelope o the lower pole o the a ected breast
to match the opposite side. In this particular case, a single operation will address a
multitude o problems: correction o in erior pole stretch de ormity, correction o
capsular contracture, rein orcement o atrophic so t tissue, correction o unsatis ac-
tory scarring o the nipples, and improvement in NAC symmetry.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the 525 cc subpectoral saline implants
Bilateral capsulectomy and implant pocket exchange
Rein orcement o the atrophic in erior poles with Strattice ADM gra ts
Correction o the le t in erior pole stretch de ormity using an eccentric circum-
areolar mastopexy
Revision o the NACs bilaterally to centralize the nipples and improve symmetry
Insertion o smaller-volume silicone gel implants into virgin submammary
pockets

Part II: Problems in Augmentation Mammaplasty
270
TECHNIQ UE
With the patient in the supine position and her arms adducted to her sides, mark-
ings were made or the surgical incisions. On the le t side an eccentric circumareo-
lar mastopexy was designed. The pattern was marked so that most o the skin ex-
cision would be rom beneath the NAC, shortening the distance rom the areola to
the IMF, to correct the in erior pole stretch that had occurred. The appropriate area
was deepithelialized and then a radial incision was made though the dermis and
parenchyma, to minimize disruption o the blood supply to the NAC. The anterior
capsule was opened, and the intact saline implant was removed.