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

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The circumareolar mastopexy de ect was closed using the periareolar pinwheel su-
ture described by Hammond. The suture was interdigitated at 45-degree intervals
around the periphery o the areola and then tightened to achieve the desired nal
areolar diameter; the knot was securely tied and deeply buried. The areola was a -
xed with staples to the adjacent wound edge, and the circumareolar incision was
closed in layers.
Once the ADM gra t was in place, it was securely sutured to the adjacent
structures. The initial repair was per ormed posteriorly, where the gra t was
sutured to the chest wall at the level o the IMF using closely spaced, inter-
rupted gure-o -eight 3-0 PDS sutures. The nal implant—in this case a
smooth round 450 cc high pro le silicone gel device—was then inserted, and
traction was applied on the marionette sutures to snugly drape the gra t over
the prosthesis. Then a small-caliber 10 Fr Jackson-Pratt drain was inserted
between the gra t and the raw sur ace o the overlying f ap, and the superior
edge o the gra t was sutured to the adjacent deep sur ace o the breast pa-
renchyma. The parenchymal incision was then repaired in layers.

Chapter 16 • Inferior Pole Stretch Deformity

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On the opposite side, similar steps were per ormed. The circumareolar excision was
more concentric, because it was unnecessary to correct in erior pole stretch on the
right side. An aggressive capsulectomy and pocket site exchange were per ormed
to minimize the risk o recurrent contracture, and a generous-sized Strattice gra t
was inserted to resur ace the thinned-out tissues o the in erior pole o the breast.
An identical pinwheel periareolar suture was placed and the circumareolar wound
closed in layers.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient’s result a ter her bilateral capsulectomies, insertion o Strattice gra ts,
asymmetrical circumareolar mastopexies, and implant exchange is shown 6 months
postoperatively.

Part II: Problems in Augmentation Mammaplasty
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The breasts are much more symmetrical, and the distance rom the nipple to the
IMF has been equalized on both sides, because the in erior pole stretch de ormity
has been recti ed. This is most evident in the lateral views. Bilateral symptomatic
capsular contracture has been corrected. The depressed scar running across the in-
erior hal o the right areola has been eliminated, the distortion and scarring o the
le t NAC has been greatly improved, and the le t nipple is now centralized within
the areola. The patient is very happy with the result o this surgery.

Chapter 16 • Inferior Pole Stretch Deformity

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TEACHING PO INTS
This case was selected as an example o correcting in erior pole stretch de ormity.
However, this woman had a constellation o problems resulting rom her previ-
ous surgeries, which occurs requently in such patients. In addition to asymmetry
caused by le t in erior pole stretch de ormity, the patient had signi cant bilateral
capsular contracture as well as distortion and scarring o both NACs. It is likely
that the in erior pole stretch de ormity that occurred on the le t side was a conse-
quence o the capsulectomy that was per ormed to treat contracture, ollowed by
the insertion o a relatively large volume, 525 cc saline implant. Tissues that are
weakened and thinned out by repeated capsulotomy and capsulectomy are more
likely to be stretched out by heavy implants; also, as a result o hydraulic transmis-
sion o orces, saline- lled devices seem more prone to cause tissue stretching than
gel- lled implants.
In treating recurrent contracture in this patient, we elected to per orm an aggres-
sive capsulectomy in conjunction with implant replacement and pocket exchange
to reduce the risk o urther recurrence o contracture. The thorough capsulectomy
urther thinned the already attenuated tissues o the lower pole o the breasts. This
was o particular concern on the le t side, where breast distortion had already oc-
curred as a result o so t tissue stretching. ADM gra ts were used to rein orce the
thinned-out in erior pole o each breast. Although a variety o ADMs were avail-
able, Strattice was selected or this particular case, because it is relatively noncom-
pliant and less likely to stretch over time.
Circumareolar mastopexy is a use ul technique, because the circum erential skin
excisions can be designed eccentrically. This allows selective reduction o certain
breast dimensions, in this case, the distance rom the nipple to the old on the le t
side to correct the in erior pole stretch de ormity. Circumareolar mastopexy also
allows some f exibility in positioning the nipple, both along the horizontal and ver-
tical axes, and enables precise control o nal areolar diameter, although the result
may not always be “permanent.” Circumareolar mastopexy has a tendency to “f at-
ten” the breast and reduce NAC projection; this can be overcome to some degree
by selecting shaped or higher pro le implants, both o which enhance projection o
the lower pole o the breast and the nipple.
BIBLIO GRAPHY
Alizadeh K. Outcome analysis o long term in erior pole support in augmentation mastopexy patients:
a 6 year ollow-up o internal autologous f aps vs. acellular dermal matrix. Plast Reconstr Surg
125:86, 2010.
Collis N, Sharpe DT. Recurrence o subglandular breast implant capsular contracture: anterior versus
total capsulectomy. Plast Reconstr Surg 106:792-797, 2000.
Hammond DC, Khuthaila DK, Kim J. The interlocking Gore-Tex suture or control o areolar diam-
eter and shape. Plast Reconstr Surg 119:804-809, 2007.
Handel N. Secondary mastopexy in the augmented patient: a recipe or disaster. Plast Reconstr Surg
118(7 Suppl):152S-163S, 2006.
Nahabedian MY. Does AlloDerm stretch? Plast Reconstr Surg 120:1276-1280, 2007.

16b Inverted-T Mastopexy With Conversion
to Submuscular Silicone Gel Implants
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 38-year-old patient had a subglandular breast augmentation with saline im-
plants 12 years previously. She has had two pregnancies with typical weight gain
and weight loss as well as postpartum atrophy o the breast tissue. She noticed pro-
gressive descent o the implants in eriorly with bottoming out. Signi cant rippling
o the subglandular saline implants was also noted, with Baker grade II capsular
contracture. She is a healthy nonsmoker with no medical problems. She requested
correction o these de ormities and desired an increase in the volume o her breasts.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has round saline implants with signi cant bottoming out, rippling, and
Baker grade II capsular contracture. She has minimal overlying breast tissue, later-
alization o the NACs, and pectus excavatum in the lower third o the sternum. The
distance rom the areola to the IMF is 9 cm on both breasts, and her nipples still sit
slightly above the IMFs. There ore this patient demonstrates bottoming out but not
ptosis. There is minimal subcutaneous tissue above the implants, and the junction
between the upper pole o the implants and the pectoralis muscle is clearly visible.
ANALYSIS O F THE PRO BLEM
In a patient with essentially no breast tissue, saline implants tend to show ripples
and wrinkles, even when the implants are appropriately lled. As demonstrated in
this patient, this phenomenon is exacerbated in patients who have had multiple
pregnancies with atrophy o the overlying breast tissue. The most signi cant com-
ponent o her breast de ormity is the bottoming out o the lower pole o the breast.
Saline implants weigh slightly more than silicone gel implants; however, some o
the increased bottoming out reported with saline implants may actually be a result
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Chapter 16 • Inferior Pole Stretch Deformity

277
o the mechanics o a noncompressible f uid such as saline within the silicone shell.
This patient also has lateralization o the NACs, especially on the le t side, which
occurred because the medial and in erior displacement o the implants rotated the
nipples laterally over time. The rippling problem is most obvious in the superior
pole o her implants because o the complete lack o so t tissue in this area as well
as the migration o the f uid to the bottom o the implant. The distance between her
clavicles and nipples is not excessive, so the problem is not one o true ptosis but
rather in erior migration o the implants themselves.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the subglandular saline implants
Creation o subpectoral pockets in continuity with the lateral posterior capsules
o the previous subglandular implants
Closure o the subglandular pockets with suture xation
Selection o silicone gel implants with proper base diameter
Contouring o the skin envelopes a ter nal implant selection, based on the in-
traoperative sequencing skin technique
TECHNIQ UE
Preoperatively her breasts were marked with an inverted-T mastopexy pattern. The
original subglandular implants were removed through the vertical component o
the mastopexy incision. Next, the lateral in erior portion o the pectoralis muscle
was identi ed and a subpectoral pocket was created. The posterior capsule o the
original subglandular implant was le t in continuity with the pectoralis muscle to
provide additional coverage o the implant laterally.

Part II: Problems in Augmentation Mammaplasty
278
The subpectoral pocket was created and temporary sizers were inserted. A ter mak-
ing an intraoperative sequencing skin pattern, we contoured the skin over the tem-
porary implants. Once the area o skin excision was con rmed, the skin was not
excised but rather deepithelialized. This deepithelialized tissue was then used as ad-
ditional overlying coverage o the implant.
The nal skin excision was per ormed once the permanent implant was inserted in
an inverted-T pattern. Because o excessive skin between the lower areola and the
IMF, a transverse skin excision was per ormed, reducing the distance rom the are-
ola to the IMF rom 9 to 5 cm.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
At 1-year ollow-up, the patient has had signi cant improvement in all parameters.
The NACs are in an appropriate location, and the distance rom the areolae to the
IMFs has been corrected. The use o larger implants with a wider base diameter has
also corrected her original de ormity.

Chapter 16 • Inferior Pole Stretch Deformity

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Insertion o the implants in the subpectoral pockets has created a more natural
slope to her breast mound, avoiding the original demarcation between the subglan-
dular implants superiorly and the pectoralis muscle.
TEACHING PO INTS
In patients who have essentially no breast tissue, subglandular saline implants tend
to provide less-than-ideal results, and in patients who have had previous pregnan-
cies with atrophy o overlying breast tissue, saline implants can be particularly
problematic. In this group o patients, saline implants appear to have a greater in-
cidence o bottoming out over time. Correction o bottoming out requires a trans-
verse skin excision in most patients. Conversion to a submuscular pocket and per-
orming an appropriate mastopexy are required.
BIBLIO GRAPHY
Barutcu A, Baytekin C. One-stage augmentation-mastopexy with Wise pattern and inverted-T scar.
Aesthetic Plast Surg 33:784-785, 2009.
Eisenberg T. Simultaneous augmentation mastopexy: a technique or maximum en bloc skin resection
using the inverted-T pattern regardless o implant size, asymmetry, or ptosis. Aesthetic Plast Surg
36:349-354, 2012.
Mou arrège R, Dionyssopoulos A, Aymeric A, Sauvageau J. [Is there a relation between mammaplas-
ties incisions and the nal shape o the breast?] Ann Chir Plast Esthet 55:111-134, 2010.
Swanson E. A retrospective photometric study o 82 published reports o mastopexy and breast reduc-
tion. Plast Reconstr Surg 128:1282-1301, 2011.

(Trang không có chữ)

C h a p t e r 17
ANIMATION DEFORMITY
ASSOCIATED WITH
SUBPECTORAL IMPLANTS
17a Use of a Neosubpectoral Pocket
Den n is C. h a mmo n d
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 47-year-old woman had undergone a subpectoral breast augmentation
through an IMF incision 4 years previously. The procedure was complicated by im-
plant malposition on the le t side, as well as the development o bilateral double-
bubble de ormities. A revisionary procedure was planned to alter the le t IMF, a
le t capsulotomy, and exchange o the right implant. She expressed concern about a
prominent distortion o the in erior pole o each breast, which was most noticeable
when she raised her arms over her head or exed her pectoralis major muscles.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
This patient has two moderate prof le plus smooth round gel implants, 325 cc on
the le t and 400 cc on the right. There is mild ptosis o the NAC, and the IMF on
each side has been lowered slightly. The original IMFs have not been completely e -
aced and are visible as double-bubble de ormities, more prominent on the right.
281

Part II: Problems in Augmentation Mammaplasty
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However, when she raises her arms or contracts her pectoralis major muscles, the
de ormity becomes quite prominent, because it creates an obvious crease through
the lower pole; this is the most troubling problem or this patient. She is pleased
with the size o the right breast and would like the size o the le t breast increased
to match that o the right.
ANALYSIS O F THE PRO BLEM
There are multiple etiologic actors or this de ormity. The anatomic relationships
at the level o the old can predispose the patient’s breasts to develop such contour
irregularities because o the di erent elastic characteristics o the breast skin above
the native old compared with the abdominal skin below the old. The skin o the
lower pole o the breast above the old typically has a thinner dermis and greater
elasticity compared with the abdominal skin below the old, which typically has
a thicker, sti er dermis. As a result, when the native old is opened up and a new
old is created at a lower level, the two skin envelope segments will redrape di er-
ently around the implant, with the supra old breast skin mildly “herniating” above
the old old and the sti er abdominal skin resisting the orce o the underlying im-
plant. This typically results in a crease running transversely across the lower pole o
the breast, even though the underlying breast implant is pushing against this area.
In addition, the thickness o the so t tissue cover above the old old can be greater
than the relatively thin abdominal skin and at, with this inequality exacerbating
the crease across the lower pole o the breast. Finally, the pull o the attachments o
the pectoralis major muscle tends to be concentrated directly at the level o the old,
which can dramatically deepen the crease ormed by the old old and create a sig-
nif cant animation de ormity. In this patient, all three elements were present, result-
ing in a severe crease across the lower pole o the breast at the location o the IMF,
creating classic double-bubble de ormities.

Chapter 17 • Animation Deformity Associated With Subpectoral Implants

283
RECOMMENDED SOLUTION TO THE PROBLEM
Because the most signif cant contribution to the lower pole de ormity in this patient
is the pull o her pectoralis major muscles, it is prudent to go with the treatment
most likely to succeed:
Taking her pectoralis major muscle out o the equation altogether by sutur-
ing it back down, thereby placing the implant in a subglandular pocket
Applying the neosubpectoral pocket technique to li t the position o the
IMF slightly, which will help to so ten the tissue inequalities at the old level
and, with the push o the implant on the lower pole o the breast, creates a
smoother lower pole contour with minimal notching
Using the right breast as the target size, an implant will be selected to in-
crease the size o the le t breast to match that o the right
TECHNIQ UE
The f rst image above shows the appearance o the native pocket with the overdis-
sected IMF. The resulting old was positioned approximately 2 cm lower than is
desirable. Through the previous incision, a subglandular pocket was created supe-
riorly above the muscle. The space between the capsule below and the so t tissue
above was care ully opened up to def ne the new ootprint or the implant medially,
in eriorly, and laterally. When the new position o the IMF above the capsule was
compared with the original location in the old implant space below the capsule, it
could be seen that the old was elevated 1 to 2 cm.
Once the new ootprint was identif ed, the anterior capsule was plicated down to
the posterior capsule with 2-0 permanent monof lament quilting sutures to prevent
redundancy in the capsule by allowing the ootprint to shi t. The leading edge o
her pectoralis major muscle was sutured down to hold it in place and to prevent
any muscle motion rom being translated to the subglandular implant lying above
the muscle. On the right, a 400 cc moderate prof le plus smooth round gel implant
was inserted to match the volume on the le t.

Part II: Problems in Augmentation Mammaplasty
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At this point it would have been reasonable to apply a skin-only circumvertical
mastopexy pattern to the breast to li t the position o the NAC and tighten the skin
envelope. As long as deeper dissection planes were not opened up during this ma-
neuver, this was a sa e and e ective way to manage the breast ptosis. However, this
patient adamantly re used any additional scars on her breast; there ore the preex-
isting ptosis was accepted as the f nal result.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The f nal result shows complete resolution o the double-bubble de ormities and
elimination o any breast animation when the patient contracts her pectoralis ma-
jor muscles or raises her arms. Breast symmetry is improved, and the position o the
old has been success ully relocated superiorly, creating a smooth lower pole con-
tour. The position o the NAC remains low; however, she is very pleased with the
corrections that have been achieved and declined any attempt at mastopexy.

Chapter 17 • Animation Deformity Associated With Subpectoral Implants

285
TEACHING PO INTS
When correcting the double-bubble de ormity, the surgeon must be very mind ul to
accurately identi y the sometimes multiple and overlapping causes o the problem.
The most common exacerbating element is the pull o the pectoralis major muscle
directly in the area o the native old, which o ten creates de ormity with contrac-
tion o the muscle. Simple muscle tone can prevent the old old rom completely
so tening despite adequate so t tissue release. There ore any correction must ocus
on eliminating the pull o the muscle in this area either by more complete release or,
as shown here, by completely removing the muscle rom consideration by suturing
it back down and putting the implant in the subglandular plane. Tissue inequalities
are minimized by readjusting the old position, as per ormed in this case by using
the neosubpectoral pocket technique. Combining these approaches can correct even
the most prominent double-bubble and breast-animation de ormities.
BIBLIO GRAPHY
Hammond DC. Discussion: The “neosubpectoral” pocket or the correction o symmastia. Plast Re-
constr Surg 124:704-705, 2009.
Massiha H. Augmentation in ptotic and densely glandular breasts: prevention, treatment, and classif -
cation o double-bubble de ormity. Ann Plast Surg 44:143-146, 2000.
Maxwell GP, Birchenough SA, Gabriel A. E f cacy o neopectoral pocket in revisionary breast surgery.
Aesthet Surg J 29:379-385, 2009.
Spear SL, Dayan JH, Bogue D, et al. The “neosubpectoral” pocket or the correction o symmastia.
Plast Reconstr Surg 124:695-703, 2009.

17b Conversion to Subglandular Pockets
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 37-year-old woman’s breasts were augmented with silicone gel implants 10
years previously. Her primary complaints were high elevation o the implants and
signif cant distortion when she contracted her pectoralis muscles. She was happy
with the overall size o her breasts, although there was no record o the actual im-
plant volume. For this very athletic woman the submuscular distortion particularly
bothered her during exercise. She was in excellent health with just the one previous
breast surgery. Her primary goals were to have a more natural appearance to her
breasts and to eliminate her severe muscle contracture de ormity.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
On examination, this patient’s implants are sitting in a relatively elevated position,
giving the NACs the appearance o sitting low on her breast mounds. The breasts
are airly symmetrical in both volume and shape. When she contracts her pectoralis
muscles, there is the typical distortion associated with subpectoral implants, with
elevation and separation o the implants. She has no chest wall abnormalities, and
NAC location, IMF, and breast volume are all relatively symmetrical.
ANALYSIS O F THE PRO BLEM
This patient had the typical distortion associated with subpectoral augmentation.
Because o the orientation o her pectoralis muscle f bers, contraction caused two
discrete phenomena: elevation o the implant and lateral separation, with widening
o the space between the implants medially.
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Chapter 17 • Animation Deformity Associated With Subpectoral Implants

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RECOMMENDED SOLUTION TO THE PROBLEM
There are two general approaches to patients with this relatively common prob-
lem: replacement o the implant in the subglandular space or lower pole capsu-
lectomy to maintain the implant in its current position. Both o these approaches
have pros and cons.
I the patient has at least 2 cm o breast tissue, exchanging the implant to the
subglandular space has the highest chance o success, although there may be a
slightly greater likelihood o capsular contracture.
However, i the patient has very little breast tissue, continuing in the submuscu-
lar pocket may be pre erred, with an aggressive lower pole capsulotomy, includ-
ing resection o the pectoralis muscle and deinnervation o the medial pectoral
nerve. Un ortunately, there is a signif cant tendency or the nerves to reinnervate,
and this o ten is only a temporary solution.
This patient was ortunate to have more than enough breast tissue, enabling us
to take this approach as her best option:
– Changing to the subglandular plane, and
– Lowering the pockets or a more natural breast mound
TECHNIQ UE
The patient’s breasts were marked, then bilateral in erior periareolar incisions were
made, with the dissection carried down to the lateral in erior margin o the pecto-
ralis muscle. Lateral to the muscle, the capsule was divided and the previous im-
Implant removed
Posterior capsule
and pectoralis major
sutured to chest wall
Dissection to
lower IMF
Subglandular
pocket dissection

Part II: Problems in Augmentation Mammaplasty
288
plants were removed. With a lighted retractor, I created a subglandular pocket over
her pectoralis muscle superiorly and medially. Laterally, I dissected anterior to the
anterior capsule o the previous submuscular pocket. Keeping the previous anterior
portion o the submuscular lateral capsule in continuity with her muscle acilitated
closure o the original subpectoral pocket. Several tacking sutures o 3-0 Vicryl
were placed between the posterior sur ace o her pectoralis muscle and the avail-
able so t tissue on the chest wall.
This potentially di f cult procedure had to be done care ully, because there is o -
ten little tissue to grab on the chest wall. In patients who have a thick subpectoral
capsule, it may be necessary to excise the capsule to acilitate closure o the pocket.
The intraoperative photo shows markings where the pocket was reed up medi-
ally and in eriorly. I placed 450 cc sizers in the neopockets; these produced a good
shape and contour. The pockets were irrigated with antibiotic solution, 450 cc per-
manent implants were inserted through the periareolar incisions, and the incisions
were closed.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
This patient obtained an excellent result, as shown in both her static and muscle-
contracting photos. In the postoperative rontal view, she shows good contour, im-
proved NAC position, and better symmetry. In the photo showing attempts at con-

Chapter 17 • Animation Deformity Associated With Subpectoral Implants

289
tracting her pectoralis muscles, no direct implant distortion is visible. In this photo,
it is important to notice the enhanced superior hollowness above the implant dur-
ing muscle contraction; this is an important way to evaluate whether the patient is
adequately contracting her muscle. This di erence can be seen with the resulting
change in the superior pole between the photo at rest and the photo at contracture.
In this patient this approach was the ideal solution and is considered success ul.
TEACHING PO INTS
The patient must have adequate breast tissue when converting rom a submuscu-
lar to a subglandular pocket. The original submuscular pocket must be adequately
closed or sealed o to prevent migration o the implant. To achieve proper implant
positioning, it is requently necessary to do a lower capsulotomy and muscle
release.
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.
Spear SL, Schwartz J, Dayan JH, et al. Outcome assessment o breast distortion ollowing submuscu-
lar breast augmentation. Aesthetic Plast Surg 33:44-48, 2009.

17c Pectoralis Repositioning With ADM
Al l en Ga br iel , G. Pa t r ic k Ma x w el l
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 41-year-old woman had one previous breast augmentation with submuscu-
lar saline implants. She then underwent two attempts at revision o the breasts. She
requested a def nitive revision to improve her aesthetic look and minimization o
her increased animation de ormity. She is a healthy nonsmoker with no signif cant
medical issues.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has a very complex problem involving in erior malposition with con-
current animation de ormity. There are two issues to be addressed: the extent o the
in erior malposition with a nonexistent IMF, and the aggressive release o the mus-
cle, which has led to muscle retraction and her animation de ormity.
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Chapter 17 • Animation Deformity Associated With Subpectoral Implants

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ANALYSIS O F THE PRO BLEM
When we see a case such as this with severe in erior malposition, the question is
whether any skin should be excised. Generally, i no mastopexy is required, there
is no need to excise skin. Once all dimensions o the breast are reestablished, the
skin will redrape. During the examination, the implant is placed in the anatomic
position and the overlying so t tissue envelope is assessed. This is sometimes easier
to assess when the patient is in a supine position. All revision patients should be
evaluated in the supine position to assess the chest wall slopes and potential lateral
malposition. All layers should be analyzed and addressed so a concise management
plan can be ormulated.
In this case the muscle is most likely retracted, and the muscle must be released and
redraped with the help o ADM (Strattice) so it can be anchored to the original
IMF. This will correct two o the patient’s major concerns. First, the muscle is an-
chored again with ADM extension, producing stability and minimizing animation;
second, the old is supported with the ADM to ensure long-term stability by sup-
porting the weight o the implant. A site change to neopectoral placement is also
critical to the revision plan. A neopectoral pocket alone may not completely sup-
port the in erior malposition, and the ADM can rein orce the repair. ADM is not
intended to be the cure or all breast issues, but it can urther rein orce the repairs
based on existing surgical principles.
RECOMMENDED SOLUTION TO THE PROBLEM
Revision augmentation with silicone implants, including one o the ollowing:
Neopectoral pockets with ADM and release o the pectoralis rom overlying
glandular tissue
Neopectoral pockets and release o the pectoralis rom overlying glandular
tissue
Neopectoral pockets with ADM
TECHNIQ UE
The revision procedure was per ormed
through the existing in ramammary
incisions.

Part II: Problems in Augmentation Mammaplasty
292
Neopectoral pockets were created and the intact saline implants were removed. The
remainder o the capsules appeared so t. The muscle was retracted rom prior re-
lease o its sternal origins. Once each neopectoral pocket was completed, a second
pocket was created by releasing the overlying pectoralis major rom the overlying
glandular tissue to ensure redraping o the muscle; 3-0 Prolene marionette sutures
were used to pull the muscle in a more caudal direction.
Sometimes the muscle is severely scarred, and redraping may be very di f cult to
achieve. In such instances two sheets o ADM or one large sheet (16 by 20 cm) may
be needed to reanchor the pectoralis extension to the IMF. This patient had mini-
mal scarring cephalad, which made it less di f cult to pull the muscle in a caudal di-
rection. Sizers were placed, and when the appropriate size was determined, the im-
plant was placed and the ADM was secured with multiple 2-0 PDS sutures.
The patient was placed in an upright position to assess the repair. Once both sides
were completed, drains were placed and Scarpa’s ascia was closed with 3-0 Vicryl
sutures, ollowed by intradermal 4-0 Vicryl and 4-0 Monocryl. The patient is seen
in an upright position immediately a ter the procedure. She was placed in a sup-
portive bra.
Subglandular pocket
created to loosen
pectoralis major and
pull it down
Previous pocket
collapsed and
sutured to
chest wall
Implant placed
in neopectoral
pocket
ADM sutured
to create new IMF

Chapter 17 • Animation Deformity Associated With Subpectoral Implants

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PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
Twenty-f ve months a ter the secondary procedure, the patient’s results are aestheti-
cally pleasing. She is shown at rest and exing her pectoral muscles.

Part II: Problems in Augmentation Mammaplasty
294
She has stable IMFs and minimal animation o her breasts.

TEACHING PO INTS
This complex revisionary case required a detailed preoperative analysis and meticu-
lous planning. When preparing or such cases, it is important to have ADM avail-
able or rein orcement i needed. Being prepared and anticipating all possible sce-
narios will minimize the time in the operating room, help to avoid surprises, and
ensure that the procedure can be per ormed as planned. In addition, many di erent
sizes and styles o implants should be available in the operating room, since preop-
eratively it is not always known what the volume o the existing implants may be.
A three-dimensional imaging system that can assess volume preoperatively can be
help ul to estimate the total volume o the breast, but the volume o the existing im-
plant will still be an unknown.
We use ADM in nearly all revision cases. The cost may seem a deterrent actor to
the patient, but the surgeon can rein orce that a reoperation would be much more
costly than the use o ADM in a def nitive revision procedure.
BIBLIO GRAPHY
Baxter RA. Intracapsular allogenic dermal gra ts or breast implant-related problems. Plast Reconstr
Surg 112:1692-1696; discussion 1697-1698, 2003.
Brown RH, Izaddoost S, Bullocks JM. Preventing the “bottoming out” and “star-gazing” phenomena
in in erior pedicle breast reduction with an acellular dermal matrix internal brassiere. Aesthetic
Plast Surg 34:760-767, 2010.
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. Revisionary breast surgery with acellular dermal matrices. Aesthet Surg J
31:700-710, 2011.
Maxwell GP, Birchenough SA, Gabriel A. E f cacy o neopectoral pocket in revisionary breast surgery.
Aesthet Surg J 29:379-385, 2009.

18a Mastopexy With Conversion to Submuscular Pocket
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 32-year-old woman presented a ter a previous breast augmentation. She was
5 eet tall and weighed 100 pounds. Because o her original degree o ptosis, the
previous plastic surgeon elected to place very large implants rather than per orm
mastopexy. The initial implants, which were lled with 700 cc saline and placed in
the subglandular plane, exacerbated the patient’s ptosis and were totally out o pro-
portion with her body habitus. A ter several months, she returned to her surgeon
C h a p t e r 18
OVERAUGMENTED BREAST
295

Part II: Problems in Augmentation Mammaplasty
296
and requested smaller implants. In a second procedure, she had 500 cc saline im-
plants inserted. This made her ptosis even worse, because the large, 700 cc implants
had stretched her skin. The patient sought consultation, because she thought that
her breasts were not only extremely ptotic, but also because they were too large
and her NACs were positioned too ar laterally.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
When the patient presented initially, she was thin with very little body at and mini-
mal breast tissue. Her NACs were displaced laterally, with the le t nipple at the
level o the anterior axillary old. Ptosis was signi cant and bottoming out exten-
sive. The distance rom the bottom o the areolae to the IMF was approximately
14 cm. She had very little so t tissue, and her sternum and upper ribs were visible
and palpable. The implants were positioned in the subglandular space. Neither sub-
muscular placement or dissection had been per ormed in her two previous proce-
dures.
ANALYSIS O F THE PRO BLEM
This particular patient has numerous problems. Her skin envelope required reduc-
tion, and her nipples needed to be moved superomedially. Fortunately, her muscula-
ture was intact. Two approaches were possible or the revision: one was to use the
available tissue, including the underlying musculature; the other involved the use o
acellular dermis. Only a couple o centimeters o breast tissue covered the subglan-
dular implants. Saline implants caused both palpable irregularities and visible wrin-
kling. The original 700 cc implants probably exacerbated the patient’s ptosis, and
she developed extreme bottoming out. Lateral displacement o the NACs may have
resulted rom overexpansion o the breasts and the resultant loose skin pockets.
When 500 cc implants were inserted, the nipples migrated laterally.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the subglandular 500 cc saline implants
Placement o 300 cc gel implants with total muscle coverage
Inverted-T mastopexy, preserving the deepithelialized skin as a dermal support
Nipple-areolar repositioning on the dermal pedicles
TECHNIQ UE
We decided to use the patient’s so t tissues and musculature. Bottoming out was
extensive. The distance rom the NAC to IMF was 14 cm, and the degree o pto-
sis was advanced, with excess skin in the lower pole; there ore we thought that an
inverted-T mastopexy was the most appropriate procedure. Markings or this pat-
tern were made.

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An argument could be made to attempt a vertical mastopexy in this patient, but
this is not the ideal solution because o the amount o skin in the lower pole. At the
time o surgery, the redundant skin that would be removed in most cases was deepi-
thelialized and used as a cellular dermal rein orcement. No tissue was actually dis-
carded, as seen in the photos that demonstrate complete deepithelialization o all
excess skin.
Pectoralis
minor muscle
Serratus
anterior
muscle
Pectoralis
major muscle
Implant
Rectus
abdominus
muscle

Part II: Problems in Augmentation Mammaplasty
298
In the next phase, a complete submuscular pocket was made using pectoralis major,
pectoralis minor, serratus, and the superior portion o the rectus abdominis mus-
cles. Total muscle coverage was critical in this patient, because she had essentially
no breast or subcutaneous tissue, similar to subcutaneous mastectomy patients.
Initially, one side was tailor-tacked and a temporary inf ated sizer inserted to al-
low evaluation o the skin envelope and breast contour. This created an appropriate
shape. The same procedure was per ormed on the other breast.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is seen preoperatively and at 3 months and 12 months postoperatively.
The signi cant change in size and the correction o NAC position, bottoming out,
and ptosis were evident. The most di cult part o this case was moving her nipples
rom lateral to medial. It is relatively easy to move nipples superiorly on di erent
types o pedicles. The other biggest challenge is to move an NAC rom a lateral to
medial position.
Nipple malposition was completely corrected on her right breast. Her le t NAC,
which was well beyond her anterior axillary old preoperatively, was signi cantly
improved, but it was slightly laterally displaced. At the 1-year ollow-up, her result
is stable with 300 cc implants. Her NACs are well positioned. She has complete
muscle coverage, which has prevented recurrence o ptosis. Total muscle coverage
and the use o gel implants reduce the chances o wrinkles, both palpable and
visible.

Chapter 18 • Overaugmented Breast

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Preoperative
12 months postoperatively
3 months postoperatively

Part II: Problems in Augmentation Mammaplasty
300
TEACHING PO INTS
Excessively large implants are not appropriate treatment or patients with breast
ptosis. Rather than correct the problem, they tend to make the problem worse by
increasing ptosis and bottoming out. As a consequence o decreasing the implant
size rom 700 cc to 500 cc, the breasts appeared even more ptotic. Although pa-
tients requently request ptosis correction without scars rom mastopexy, only in
cases o minimal ptosis do implants actually result in improvement. Usually the
improvement seen in mildly ptotic breasts with implants is anterior rotation o the
NAC, which creates the appearance o a minimal li t. In this patient, the degree o
postpartum ptosis was ar too great to be improved with implants alone.
BIBLIO GRAPHY
Codner MA, Mejia JD, Locke MB, Mahoney A, Thiels C, Nahai FR, Hester TR, Nahai F. A 15-year
experience with primary breast augmentation. Plast Reconstr Surg 127:1300-1310, 2011.
Maxwell GP, Birchenough SA, Gabriel A. E cacy o neopectoral pocket in revisionary breast surgery.
Aesthet Surg J 29:379-385, 2009.
Naidu NS, Patrick PA. The inf uence o career stage, practice type and location, and physician’s sex on
surgical practices among board-certi ed plastic surgeons per orming breast augmentation. Aes-
thet Surg J 31:941-952, 2011.
Stutman RL, Codner M, Mahoney A, Amei A. Comparison o breast augmentation incisions and com-
mon complications. Aesthetic Plast Surg 36:1096-1104, 2012.

18b Conversion to Subglandular Pocket
n ea l h a n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 26-year-old model and aspiring actress presented with multiple concerns re-
lated to breast augmentation per ormed 2 years earlier. She was a petite, nullipa-
rous woman who stated that she “always had small breasts and barely lled an A
cup.” Her initial plastic surgeon inserted 275 cc Moderate Pro le silicone gel im-
plants (Mentor, Santa Barbara, CA) in the subpectoral plane. At the same opera-
tion, a bilateral circumareolar (Benelli) mastopexy was per ormed. The patient
requested silicone implants, and her surgery was per ormed while the FDA mora-
torium on their use was in e ect. She believed that a periareolar mastopexy was
recommended primarily to quali y her or gel implants by diagnosis o ptosis that
required a mastopexy or correction. The patient’s chie concerns were that her
breasts were much too large or her rame, her areolae were excessively wide, and
she had a double-bubble de ormity o her right breast.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient is petite, and her breasts are much too large or her small rame and
out o proportion with the rest o her body. Her upper poles are excessively ull
and convex, and the lateral borders o her breasts extend well beyond the anterior
301

Part II: Problems in Augmentation Mammaplasty
302
axillary line on both sides. Despite her previous periareolar mastopexy, her breasts
are slightly ptotic. The right nipple measures 1 cm lower than the le t. Her are-
olae are very dilated and eccentrically shaped, each measuring 6 cm in width and
7 cm in height. Her nipples are not centered within the pigmented areolar skin. The
implants are in the subpectoral position, and when the patient f exes her pectoral
muscles, her breasts become considerably f attened and distorted. The le t implant
has dri ted slightly laterally, resulting in a widened, asymmetrical area o cleavage.
A double-bubble is evident on the right side. Both breasts are so t (Baker grade I).
ANALYSIS O F THE PRO BLEM
The patient presented with extremely overaugmented breasts. The implants inserted
at the time o her primary augmentation were too large be accommodated by her
small so t tissue envelope and too wide in base diameter to t her relatively nar-
row hemithorax. The circumareolar mastopexy was unnecessary and urther exac-
erbated the problem by reducing the amount o so t tissue available to support the
implant. The large, overly wide implants resulted in unaesthetic upper pole convex-
ity, excessive lateral ullness, and a double-bubble on the right side. The mastopexy
increased tension on her so t tissue envelope, leading to stretched and de ormed
areolae. The presence o large implants in relatively tight subpectoral pockets re-
sulted in undesirable f attening and distortion o her breasts when the muscles were
activated. The patient had adequate so t tissue (more than 2 cm o pinch thickness
at the upper border o the breast and in the parasternal region) to allow conversion
o the implants to a submammary pocket.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the large-volume, wide-base subpectoral implants
Secure reattachment o the pectoral muscle to the chest wall
Creation o a virgin submammary pocket to accommodate implants with a
smaller base diameter and eliminate the downward and lateral orce vector gen-
erated by muscle contraction
In erior capsuloplasty to eliminate the double-bubble and elevate the IMF
Insertion o smaller-volume, High Pro le silicone gel implants (Mentor)
TECHNIQ UE
Preoperative measurements and skin markings were made with the patient in the
standing position to ensure symmetrical placement o her nipples. In the operating
room, she was placed supine with her arms at her side (adducted) to relax tension
on the pectoral muscle. Two concentric circles were drawn around the nipple. The
outer circle was just large enough to incorporate all o the pigmented areolar skin

Chapter 18 • Overaugmented Breast

303
(approximately 7 cm diameter), and the inner circle was small enough to exclude
nonpigmented skin beyond the areolar border (approximately 5 cm). The concen-
tric circles were incised and the area between them deepithelialized. The wound
was deepened through the dermis in eriorly to the level o the pectoral muscle.
With the submuscular implant in situ a new submammary pocket was dissected.
The capsule was then opened and the implant removed. The existing implants mea-
sured 275 cc and were gel- lled round Moderate Pro le devices. The undersur ace
o the pectoral muscle (anterior capsule) and the subadjacent chest wall (posterior
capsule) were roughened with electrocautery to create resh tissue sur aces. The
muscle was then approximated with the chest wall, placed in its normal anatomic
position, and secured to the underlying muscles and ascia with interrupted gure-
o -eight 2-0 PDS sutures.
A crescent o scar tissue lining the in eriormost portion o the existing capsule was
excised, and capsuloplasty was per ormed by suturing the cut edges with a running,
locked nonabsorbable suture (0 Prolene). A sizer was inserted, and the patient was
placed in the sitting position on the operating table to ensure that the new sub-
mammary pocket was properly situated with respect to the nipple, the medial and
lateral borders o the breast were in the desired position, and the contour o the
newly de ned IMF was smooth. Irregularities in the contour o the pocket (medi-
ally, laterally, or in eriorly) were corrected by judicious electrocautery dissection.
A 200 cc smooth round High Pro le silicone implant was inserted into the pocket
and the parenchymal incision closed in layers. The periareolar mastopexy was com-
pleted with placement o a deep dermal “pinwheel” suture (described by Ham-
mond). A purse-string suture was tightened to reduce the diameter o the outer cir-
cle to 4 cm. The knot was tied and buried. The areola was sutured without tension
to the peripheral wound. Identical steps were per ormed on the contralateral side.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient had an unevent ul postoperative recovery and achieved an excellent re-
sult. Her smaller, narrower breasts are much better suited to her petite rame.

Part II: Problems in Augmentation Mammaplasty
304
The excessive upper pole and lateral ullness o the breasts is eliminated. The
double-bubble is corrected, the diameter o her areolae is reduced, and her nipples
are centralized within the pigmented areolae. Her cleavage is symmetrical, and she
no longer has animation de ormity associated with pectoral muscle activation.

Chapter 18 • Overaugmented Breast

305
TEACHING PO INTS
In recent years a great deal o attention has been directed to scienti c methods or
selecting appropriate implant size and shape. Although several implant sizing sys-
tems have been popularized, the underlying principles are universal. Surgeons need
to consider the width o the hemithorax, the desired diameter o the nal breast,
the thickness o the existing so t tissue envelope, and the degree o elasticity o the
native breast. Personal patient pre erences should be taken into account, including
the degree o augmentation desired, the amount o upper pole ullness requested,
and how natural the patient wants to look a ter augmentation. A range o sizes and
shapes may be suitable or a patient’s anatomy; there ore personal pre erences are
invaluable when making the nal decision.
Just as several sizes/shapes will provide satis actory results in most patients, there
are even more options that can result in a bad outcome, the type o unaesthetic re-
sult seen in this case. Overaugmentation is ar more common than underaugmenta-
tion and o ten results rom a surgeon’s attempt to meet a patient’s unrealistic size
expectations or to avoid per orming a mastopexy in a patient with signi cant pto-
sis. Correction o overaugmented breasts requires that certain objectives are met.
The correct, new implant size must be determined based on the anatomic criteria
outlined previously. The overly dissected pocket must be reduced in dimensions.
This can be accomplished by plication o the existing periprosthetic capsule with
some type o capsulorrhaphy or capsuloplasty, creation o a virgin pocket in the
neosubmammary or neosubpectoral plane, or conversion rom a subpectoral to a
submammary plane (to create a virgin pocket o proper dimensions). When an ad-
equately abundant so t tissue envelope is present, conversion rom subpectoral to
submammary location reduces the risk o later in erior and lateral implant dri t and
reduces the risk o a double-bubble.
BIBLIO GRAPHY
Elliott LF. Circumareolar mastopexy with augmentation. Clin Plast Surg 29:337-347, 2002.
Hammond DC. Implant selection in breast augmentation. Presented at the Eighty-ninth Annual Meet-
ing and Aesthetic Symposium o the American Association o Plastic Surgeons, San Antonio, TX,
March 2010.
Hammond DC, Khuthaila DK, Kim J. The interlocking Gore-Tex suture or control o areolar diam-
eter and shape. Plast Reconstr Surg 119:804-809, 2007.
Hidalgo DA. Breast augmentation: choosing the optimal incision, implant, and pocket plane. Plast Re-
constr Surg 105:2217-2218, 2000.
Tebbetts JB, Adams WP. Five critical decisions in breast augmentation using 5 measurements in 5 min-
utes: the high ve system. Plast Reconstr Surg 116:2005-2016, 2005.
Tebbetts JB. A system or breast implant selection based on patient tissue characteristics and implant-
so t tissue dynamics. Plast Reconstr Surg 109:1396-1409, 2002.

18c Implant Replacement and ADM
Fo a d n a h a i
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 34-year-old woman consulted with us a ter two previous, unsuccess ul breast
augmentations. During the original procedure, saline implants were placed in a
subpectoral position. The patient was unhappy with the result, claiming that her
breasts were now asymmetrical and she had a line across the le t breast with a
double-bubble appearance. To correct these problems, she underwent a second pro-
cedure in which her saline implants were exchanged or larger saline implants. No
adjustments were made to her pockets or IMFs. No urther in ormation was avail-
able concerning the type o implant, volume o saline, or the level and extent o the
dissection. When the patient consulted with us, her major concerns were her signi -
cant breast asymmetry, malposition o the NAC on each side, nipples pointing too
ar laterally, lack o a distinct IMF, and the unnatural shape and disproportional
size o her breasts. She was in good health and a nonsmoker.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient demonstrates numerous problems typically associated with overdis-
section o the IMF and placement o inappropriately large implants in an overdis-
sected submuscular pocket. Her implant pockets are too medial, with visible rip-
pling more noticeable on the le t. The nipples point laterally and she has severe,
bilateral double-bubble de ormity. Her IMFs are low, and a restriction band is pres-
ent below the le t NAC. Her breasts have an unnatural shape, with too much me-
dial ullness and de cient lateral ullness. Her IMFs are totally e aced. The crease
below the le t nipple-areola appears to be a remnant o the previous IMF.
ANALYSIS O F THE PRO BLEM
The patient’s saline implants were too wide and too heavy. The le t breast pocket
was too medial, and had visible rippling and restriction. Both pockets were too low.
306

Chapter 18 • Overaugmented Breast

307
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the implants and replacement with silicone gel implants o appro-
priate size, dimension, and pro le
Readjustment o both breast pockets
Application o an acellular dermal matrix to reduce rippling and rein orce the
adjustment o the breast pockets
TECHNIQ UE
The tertiary procedure was per ormed through her previous IMF incision. The in-
cision was carried down to the previous, very thin, capsule. This was opened, and
the heavy, oversized but intact saline implants were removed. Multiple internal cap-
sulorrhaphies were per ormed with absorbable and permanent sutures. These were
positioned to reestablish the preexisting IMF and to adjust the medial extent o
each breast pocket.
First layer:
Permanent suture (Prolene)
Second layer:
Absorbable suture (PDS)
Transcutaneous needles were placed to identi y the
exact position and location or the internal capsulor-
rhaphy. This was per ormed in two layers, with in-
terrupted Prolene sutures or the deep layer and PDS
sutures or the second layer.
Transcutaneous
needle indicates
repair site
First layer:
Permanent suture
(Prolene)

Part II: Problems in Augmentation Mammaplasty
308
An AlloDerm patch (Li eCell, Branchburg, NJ) was sutured into the medial side o
her le t breast to eliminate rippling. Smaller silicone gel implants with more appro-
priate base dimensions were placed in this revised subpectoral pocket.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 6 months postoperatively. Her breast asymmetry and double-
bubble de ormity are corrected, the IMF is reestablished in the appropriate posi-
tion, and her breasts have a more natural appearance and size with appropriately
positioned nipples.

Chapter 18 • Overaugmented Breast

309
TEACHING PO INTS
The size o the implants needs to be matched to the patient’s overall body habitus.
The dimensions, size, and weight o the implants selected or this patient were inap-
propriate.
Underlying problems need to be treated. A ter one unsatis actory result, this
woman had a second procedure in which the implants were exchanged or larger
implants. However, the underlying issues were not corrected. These included the in-
appropriate choice o implant, excessive dissection o the pocket, an indistinct IMF,
and excessive medial dissection o the pockets and release o the pectoralis, espe-
cially on her le t side.
BIBLIO GRAPHY
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, Gabriel A. Use o the acellular dermal matrix in revisionary aesthetic breast surgery.
Aesthet Surg J 29:485-493, 2009.

18d Multidirectional Capsulorrhaphy Reinforced
With ADM
n ea l h a n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 29-year-old woman was re erred by her plastic surgeon. She had our previ-
ous breast operations by two di erent surgeons and was unhappy with her out-
come. She reported that she was “always small breasted and barely lled an A-cup
bra.” She had her initial augmentation at age 19, with submammary 300 cc tear-
drop-shaped saline implants. Shortly therea ter, she noted that her implants were
too close together, with loss o normal cleavage. A year later, her rst surgeon at-
tempted a revision with removal and replacement o her implants with smooth
round saline devices. The patient stated that her synmastia was even worse a ter
the revision. She sought care rom another plastic surgeon a year later, who rec-
ommended correction in two stages. In the rst stage, the implants were removed
and le t out or approximately a month. In the second stage (the ourth operation),
400 cc Mentor Moderate Pro le silicone gel implants were inserted in the subpecto-
ral position. The patient alleged that the surgeon’s o ce sta talked her into larger
implants than she wanted. Immediately a ter surgery, she thought that her implants
were not only too big but they were much too low. Over time, bottoming out pro-
gressed urther. When she presented to us or revision, her complaints were that her
breasts were too large, too low, and too close together.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient is a healthy, relatively petite young woman. She is 5 eet our inches tall
and weighs 120 pounds. She had had augmentation mammaplasty through in ra-
mammary operative incisions. Her breasts are so t (Baker grade I on both sides).
They are disproportionally large or her rame, low on her chest, and excessively
wide. Synmastia is evident when the implants are pushed toward the midline. When
the patient lies supine, the lateral borders o her breasts extend ar beyond the an-
terior axillary line, almost to the midthoracic line. The surgical scars are quite long
(approximately 7 cm) and have widened. Because the implants have descended,
310

Chapter 18 • Overaugmented Breast

311
the scars are no longer in the IMFs; they are on the anterior sur ace o the in erior
poles. A pinch test demonstrates 2.0 cm o tissue thickness medially (parasternal
region) and slightly more than 2.0 cm thickness laterally. Based on measurement
o the patient’s hemithorax, the ideal breast base diameter or her width ( rom
the medial edge o the native breast to the anterior axillary line) is approximately
12.5 cm. The patient desires breasts that are smaller than her rst set o implants,
which were 300 cc.
ANALYSIS O F THE PRO BLEM
A ter multiple breast implant procedures that involved the insertion o progres-
sively larger implants and injudicious pocket enlargement, the patient presented
with a number o problems. As a result o a series o inappropriate surgical choices,
she had overaugmented breasts. Not only were her breasts out o proportion to her
relatively petite rame, but she also had implants that were much too wide or her
native breast base diameter, resulting in medial overextension o the breast (syn-
mastia) and excessive lateral projection. The excessively large implants also contrib-
uted to bottoming out, which made her IMFs too low (on the upper abdomen) and
her surgical scars visible on the anterior sur ace o her breasts.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the subpectoral silicone implants through the existing scars
Secure reattachment o the pectoral muscles to the chest wall
Creation o a neosubmammary pocket o correct dimensions and in the appro-
priate position to prevent recurrent synmastia and lateral implant malposition
Capsulorrhaphy to reduce the in erior dimensions o the pocket
Rein orcement o the in erior capsulorrhaphy with an acellular dermal matrix
(ADM) overlay gra t (Strattice; Li eCell, Branchburg, NJ)
Insertion o a new pair o smaller-volume, narrower base diameter, higher-
pro le, smooth silicone gel implants
TECHNIQ UE
With the patient supine on the operating table, it
was evident that the implants were much too wide
or her native breast base diameter. The lateral bor-
ders o the breasts extended beyond the midthoracic
line. The in erior borders descended well onto the
upper abdomen, and the scars were on the anterior
sur ace o the breast, instead o in the IMF.

Part II: Problems in Augmentation Mammaplasty
312
The midline o the sternum was marked, and lines were drawn to delineate the pro-
posed medial borders o the breasts, approximately 1.0 cm on either side o mid-
line. When the implants were pushed toward the midline, synmastia was obvious.
The so t tissues had been dissected too ar medially, and there was no longer su -
cient attachment o presternal skin to underlying periosteum.
The old scar was excised to expose the anterior capsule. The 400 cc moderate pro-
le silicone implants were removed and placed atop the breast; the excessive base
diameter was evident. The lateral border o the pectoral muscle was identi ed and
grasped with Allis clamps to acilitate dissection o a new retromammary pocket.
Once the muscle was adequately reed, it was approximated to the underlying chest
wall and securely xated with interrupted gure-o -eight sutures o 2-0 Prolene. A
new submammary pocket o the correct dimensions was created, with care taken
not to dissect too ar medially or too ar laterally. A sizer was placed in the pocket
and correct positioning o the implant was visually con rmed. The breast now ex-

Chapter 18 • Overaugmented Breast

313
tended laterally only to the anterior axillary line, and the desired cleavage was
achieved. Although the new sizer was much smaller than the previous implant, the
breast actually had more projection.
A 10 Fr round silicone drain was interposed between the ADM gra t and the over-
lying f ap and beneath the pectoral muscle to prevent f uid accumulation and pro-
mote tissue adhesion. The ADM was sutured to the posterior chest wall at the
appropriate level. The sizer was reinserted and the ADM gra t draped over it to
determine exactly where the anterior edge o the gra t will be sutured to the breast
parenchyma. Once this location was marked, the sizer was removed, and the per-
manent implant was prepared or insertion. A 225 cc smooth round Moderate Plus
implant (Mentor) with a base diameter o 10.9 cm and a projection o 3.3 cm was
chosen. With the implant in place, the anterior edge o the ADM gra t was sutured
to the overlying breast parenchyma, and the operative incision was closed in layers.
Identical steps were per ormed on the contralateral size. The patient is shown at the
completion o surgery.
An in erior capsulorrhaphy was per ormed by ex-
cising the appropriate crescent o scar capsule and
closing the de ect with a running, locked, nonab-
sorbable suture (0 Prolene). An appropriate-size
piece o Strattice was selected and inserted in ham-
mocklike ashion to rein orce the suture repair o
the capsule.

Part II: Problems in Augmentation Mammaplasty
314
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient had a routine postoperative recovery and achieved a good result. She is
shown 11⁄2 years postoperatively. Her breasts are considerably reduced in size, and
the implants are much better positioned on her chest. Synmastia is eliminated, im-
plant bottoming out is corrected, and the lateral borders no longer extend beyond
the anterior axillary line. Her scars are better hidden in the IMFs.

Chapter 18 • Overaugmented Breast

315
TEACHING PO INTS
This case illustrates how a series o injudiciously per ormed implant revision opera-
tions with insertion o progressively larger and larger implants can result in numer-
ous problems. This patient presented with overaugmented breasts with megapock-
ets that were overenlarged in virtually all directions. In such a case, a signi cantly
smaller implant must be inserted to correct overaugmentation.
The volume and pro le o the new implant was determined by applying the prin-
ciples o the BodyLogic System (Mentor) or implant selection. Measurement o the
hemithorax suggested an ideal nal breast base diameter o approximately 12.5 cm.
Subtraction o the medial breast tissue f ap thickness (hal o 2.0 cm 5 1.0 cm) and
the lateral breast f ap thickness (hal o 2.0 cm 5 1.0 cm) indicated that a breast
implant with a base diameter o about 10.5 to 11.0 cm was needed to obtain the
desired breast base width. This base width can be achieved using Moderate Plus im-
plants o 200 cc, 225 cc, or 250 cc.
Because the dimensions o the new implant were much smaller than the size o the
existing pockets, pocket dimensions needed to be reduced. In this patient, the de-
sired result was achieved by exchange o the implant into a virgin space, combined
with capsulorrhaphy and rein orcement o the repair with an ADM gra t. Conver-
sion o the new implant rom a subpectoral to a submammary plane not only acili-
tated creation o a properly sized pocket, but it also eliminated the downward and
lateral orce vector generated by the muscle, which can disrupt the repair and pre-
cipitate recurrence o the de ormity.
BIBLIO GRAPHY
Adams WP, Teitelbaum S, Bengston BP, et al. Breast augmentation roundtable. Plast Reconstr Surg
118(7 Suppl):S175-S187, 2006.
Baxter RA. Intracapsular allogenic dermal gra ts or breast implant-related problems. Plast Reconstr
Surg 112:1692-1696, 2003.
Chasan PE. Breast capsulorrhaphy revisited: a simple technique or complex problems. Plast Reconstr
Surg 115:296-301, 2005.
Hammond DC, Hidalgo D, Slavin SA, et al. Revising the unsatis actory breast augmentation. Plast
Reconstr Surg 104:277-283, 1999.
Mo d MM, Singh NK. Pocket conversion made easy: a simple technique using AlloDerm to convert
subglandular breast implants to the dual-plane position. Aesthet Surg J 29:12-18, 2009.
Spear SL, Little JW III. Breast capsulorrhaphy. Plast Reconstr Surg 81:274-279, 1988.

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19a Conversion to Partial Subpectoral Pockets
With Mastopexy
Lo u is L. St r o c k
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 50-year-old woman had undergone breast augmentation 20 years previously.
Her postoperative course was complicated by severe capsular contractures result-
ing in two revision procedures per ormed by the initial surgeon. Her most recent
revision was 10 years earlier, at which time she had undergone bilateral total capsu-
lectomy with silicone gel implant replacement using 330 cc round textured devices.
The subglandular implant position had been used or the initial and all previous
revision procedures. She also reported that she had experienced recurrent implant
rmness, severe in nature, soon a ter each o her revision procedures. She now re-
quested enhanced breasts with improved shape and so tness. She also asked that
the procedure correct the drop in position o her breast tissue relative to the im-
plant. This woman is a healthy nonsmoker with no signi cant medical issues.
c h a Pt e r 19
PTOSIS IN PREVIOUSLY
AUGMENTED BREASTS
317

Part II: Problems in Augmentation Mammaplasty
318
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
This patient presents with a combination o issues that are not unusual many years
a ter a breast enhancement procedure. The rst issue is ptosis o her breast tissue
relative to the implant. This is accentuated by the second issue, which is recurrent
capsular contracture with coexisting superior breast implant malposition. She has
Baker grade III capsular contracture on the right and Baker grade II on the le t, as
well as slight breast and chest asymmetry. Although her tissue is ptotic with mul-
tiple stretch marks, she has a moderate amount o breast tissue. The estimated pro-
portion o total breast volume provided by her existing implant is 70% . Her NACs
are slightly asymmetrical in appearance and location, lateralized bilaterally. She has
no signi cant di erences in IMF position or shape, with previous IMF incisions
present bilaterally. There is no implant movement noted with pectoral muscle con-
traction, which is consistent with the subglandular implant location.
ANALYSIS O F THE PRO BLEM
Many patients with breast implants have an “aesthetic deterioration” over many
years, which most commonly centers on a gradual progression o breast tissue pto-
sis. Although this can be tolerated as an isolated issue or many years, the combi-
nation o progressive tissue ptosis with capsular contracture is a power ul driver to
reoperation. Absolute ptosis appears signi cantly worse when combined with the
relative tissue ptosis that results rom signi cant capsular contracture with superior
implant malposition. Speci c to this patient, there are two main issues to be ad-
dressed with surgical revision: her breast tissue ptosis, and her problem o recurrent
capsular contractures.
RECOMMENDED SOLUTION TO THE PROBLEM
Removing the implants
Per orming a subtotal or total capsulectomy, which was the approach chosen
a ter intraoperative evaluation
Replacing the implants with pocket site change rom the subglandular to the
partial subpectoral space
Per orming a vertical mastopexy

Chapter 19 • Ptosis in Previously Augmented Breasts

319
TECHNIQ UE
Because a vertical mastopexy was planned, this approach was used rst to access
the existing breast implant pocket. A ter peripheral deepithelialization and demar-
cation o the NAC using a 42 mm cookie cutter, the breast tissue was incised to
the implant capsule. The textured gel implants were removed and noted to be in-
tact, without evidence o rupture or gel bleed. The implant capsule was noted to be
thickened, but not calci ed, and otherwise unremarkable. A subtotal capsulectomy
was per ormed, maintaining the existing capsule just above and below the IMF and
preserving the tissue attachments in this area. A ter irrigation o the subglandular
space with antibiotic solution, which was hal -strength povidone-iodine (Betadine)
as o -label use a ter preoperative patient consent, the lateral border o the pectora-
lis major was mobilized and the subpectoral space entered.
The pectoralis major was dissected, leaving the in erior aspect o the implant cap-
sule connected to the in erior edge o the muscle along the IMF. The lateral pecto-
ralis major was tacked to the undersur ace o the breast tissue both to stabilize the
position o the muscle and to avoid communication between the subglandular and
subpectoral spaces. The lateral aspect o the serratus anterior was mobilized, on a
limited basis, and was tacked to the lateral breast tissue internally to create the lat-
eral con ne o the partial submuscular space. There was no distortion o IMF level
or shape a ter creating and stabilizing the partial subpectoral pocket in the manner
outlined.

Part II: Problems in Augmentation Mammaplasty
320
A chest wall measurement was taken, indicating an 11.7 cm base width 350 cc high
pro le smooth wall silicone gel implant. The device type was agreed on with the
patient during preoperative consultation, with speci c width to be chosen based
on intraoperative ndings rom a group o devices agreed on in advance. The de-
vice was placed in antibiotic solution and then inserted into the partial subpec-
toral pocket with the aid o an insertion sleeve. Once the desired IMF shape was
con rmed, a small closed suction drain was placed. A vertical mastopexy was then
con gured using a tailor-tack technique. Once adequate shape was con rmed, an
identical procedure was per ormed on the contralateral side. A ter making minor
adjustments, we excised the tissue within the tailor-tack markings, care ully main-
taining a layer o breast tissue over the implant in all areas possible. De nitive clo-
sures were completed in a multilayer ashion, and a pressure dressing was placed
on completion o the procedure.