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

Part II: Problems in Augmentation Mammaplasty
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TEACHING PO INTS
Subtotal capsulectomy can be used in selected patients to acilitate tissue stabil-
ity when converting rom a subglandular to a partial subpectoral implant tissue
pocket. This is a valuable approach i the IMF level and shape is to be preserved,
but this approach must be weighed against the sa ety o incomplete removal o the
existing implant capsule in each patient. Site change procedures are the approach o
choice in treating capsular contracture. Mastopexy was per ormed as a nal step in
this revisional breast enhancement procedure, a ter dimensional stabilization o the
implant pocket at the time o device replacement; the rationale or using this ap-
proach is so that the breast tissue will contribute very little to the mechanical sup-
port o the breast implant.
BIBLIO GRAPHY
Spear SL, Carter ME, Ganz JC. The correction o capsular contracture by conversion to “dual-plane”
positioning: technique and outcomes. Plast Reconstr Surg 118(7 Suppl):103S-113S, 2006.
Young VL. Guidelines and indications or breast implant capsulectomy. Plast Reconstr Surg 102:884-
891, 1998.

19b Neosubpectoral Pocket Exchange
Lo u is L. St r o c k
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 51-year-old woman presented or revision breast enhancement a ter a recent
rupture o her right breast implant. She had originally undergone breast augmenta-
tion approximately 20 years previously with silicone gel implants placed in a sub-
glandular pocket. Her postoperative course rom that procedure was complicated
by capsular contractures that resulted in an exchange to saline implants with con-
version to partial subpectoral pockets, per ormed by her original surgeon. She re-
ported that her saline implants had been f rm or many years and that she did not
like the ullness in the upper area o her breasts. She also reported that the position
o her breast tissue had dropped in recent years. She requested that the additional
revision procedure correct her ruptured right implant and low breast tissue posi-
tion, to provide her with improved shape and a more natural appearance to her
breasts. This woman is a healthy nonsmoker with no signif cant medical issues.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
This patient has a combination o issues that are not an unusual occurrence many
years a ter breast enhancement. The f rst issue is ptosis o her breast tissue relative
to the implant. Additionally, she has a Baker grade III capsular contracture on the
le t side with superior implant malposition. The rupture o the right breast implant
was recent. She has airly tight breast tissue, with a pinch thickness o 3 cm and
mild ptosis o 3 to 4 cm. She has mild asymmetry o her breast tissue and NAC lo-
cation. Her implant contribution to her overall breast volume on the le t side is esti-
mated to be approximately 50% . Implant movement is noted with pectoral muscle
contraction, which is consistent with the partial subpectoral implant location.
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Part II: Problems in Augmentation Mammaplasty
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ANALYSIS O F THE PRO BLEM
This patient had aced numerous challenges in her postoperative course a ter breast
enhancement. She had recurrent capsular contractures, which were treated with a
conversion rom a subglandular to partial subpectoral pocket location at the time
o the replacement o silicone gel implants with saline implants. In addition to the
recurrent capsular contractures, she noted a right implant rupture that occurred re-
cently. Her tissue had also dropped in position, which was made more severe in ap-
pearance by superior device malposition that resulted rom the recurrent contrac-
ture. Interestingly, with all these issues present, it was the right implant rupture that
nally led the patient to pursue this additional revision procedure. The main issues
to be addressed with revision included the rupture o the right implant, recurrent
contracture, and ptosis o breast tissue.
RECOMMENDED SOLUTION TO THE PROBLEM
Removing the implants
Evaluating the implant pocket with capsule management through capsulotomy,
total or subtotal capsulectomy, or creating a neopectoral pocket, to be deter-
mined pending intraoperative ndings
Replacing the implants with pocket site change through capsulectomy or creat-
ing a neopectoral pocket
Per orming mastopexy
TECHNIQ UE
Because a vertical mastopexy was planned, this approach was used to access the
existing right breast implant pocket. A ter peripheral deepithelialization and de-
marcation o the NAC using a 42 mm cookie cutter, the breast tissue and pectoralis
major layers were incised to the implant capsule.

Chapter 19 • Ptosis in Previously Augmented Breasts

325
The implant capsule was inspected and ound to be slightly thickened, but other-
wise unremarkable. It was thought that a neopectoral pocket would have to be cre-
ated, to create a new tissue pocket or the implant to be used with improved pe-
ripheral dimension control compared with capsulectomy. The neopectoral pocket
was created by dissecting a tissue plane between the pectoralis major muscle and
the anterior implant capsule. An incision was made in the implant capsule, which
allowed or the removal o the ruptured 325 cc saline implant. The tissue pocket
was irrigated with hal -strength povidone-iodine (Betadine), a ter preoperative o -
label consent was obtained, and the capsule incision closed. Additional re nements
o the neopectoral pocket were completed.
Once the peripheral extent o the pocket was con rmed to be adequate, the neopec-
toral pocket was irrigated with hal -strength Betadine and a local anesthetic solu-
tion. The anterior capsule wall was then tacked to the posterior sur ace in multiple
areas. A chest wall measurement was taken, corresponding to a 12 cm base width
375 cc high pro le smooth wall round gel device. The device was soaked in antibi-
otic solution, and placed into the neopectoral tissue pocket with the aid o an inser-
tion sleeve. Excellent IMF shape was con rmed with the patient in the sitting posi-
tion. She was returned to the supine position, a small closed suction drain placed,
and a vertical mastopexy con gured using a tailor-tack technique. Excellent breast
shape was con rmed with the patient in a sitting position.

Part II: Problems in Augmentation Mammaplasty
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On the le t side, an incision was made through the breast tissue and pectoral mus-
cle to the implant capsule. The tissue plane was then developed between the pec-
toralis major and the anterior capsule layer. To the extent possible, this dissec-
tion was completed with the implant in place. The capsule was then incised and
the implant removed. Inspection o the internal capsule space was unremarkable,
with slight thickening noted. Creation o the neopectoral pocket was then com-
pleted. The previous tissue pocket was irrigated with hal -strength Betadine, a ter
which the incision in the anterior capsule used to remove the implant was closed,
and the anterior capsule was tacked down to the posterior capsule in several loca-
tions to close the old pocket. The neopectoral pocket was irrigated with antibiotic
solution, a ter which a 375 cc high pro le smooth round silicone gel implant was
soaked in antibiotic solution and placed into the neopectoral pocket with the aid o
an insertion sleeve. The patient was again placed in sitting position to con rm that
both the extent o the implant pocket and the IMF shape were acceptable. A closed
suction drain was placed, and a vertical mastopexy con gured using a tailor-tack
technique. Excellent breast shape was con rmed by placing the patient in a sitting
position, and then she was returned to the supine position and de nitive closure
per ormed bilaterally. On completion o the procedure the patient was placed in a
pressure dressing.

Chapter 19 • Ptosis in Previously Augmented Breasts

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PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The postoperative photographs at 12 months a ter this patient’s breast implant re-
placement show correction o her breast tissue ptosis with a stable outcome. There
is a slight degree o asymmetry o her breast tissue, but her breast shape is excel-
lent overall. She has maintained a so t result with no evidence o recurrent capsular
contracture.

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TEACHING PO INTS
Creation o a neopectoral or neosubpectoral pocket can be a valuable approach
in secondary breast enhancement. This approach is use ul in conjunction with the
inspection o an implant capsule that is noted to have minor thickening but is oth-
erwise normal. This approach would not be advisable in the context o a severely
thickened capsule, ruptured gel implant, or signi cant calci cation. Alternatively, i
additional evaluation suggests that complete capsulectomy is needed, the conver-
sion rom a neopectoral pocket dissection requires the removal o the posterior cap-
sule. Site change procedures are the pre erred approach to treating capsular con-
tracture. Creating a neopectoral pocket can be a pre erred and simple approach to
a site change in a patient with preexisting partial subpectoral breast implants.
Mastopexy was per ormed as a nal step in this patient’s revision breast enhance-
ment procedure. It is per ormed a ter dimensional stabilization o the implant
pocket at the time o device replacement. The rationale or per orming a masto-
pexy is to minimize the contribution o the breast tissue to the support o the breast
implant.
BIBLIO GRAPHY
Maxwell GP, Birchenough SA, Gabriel A. E cacy o neopectoral pocket in revisionary breast surgery.
Aesthet Surg J 29:379-385, 2009.
Maxwell GP, Gabriel A. The neopectoral pocket in revisionary breast surgery. Aesthet Surg J 28:463-
467, 2008.
Spear SL, Dayan JH, Bogue D, et al. The “neosubpectoral” pocket or the correction o symmastia.
Plast Reconstr Surg 124:695-703, 2009.

19c Mastopexy Without Implant Exchange
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 34-year-old patient had undergone a subpectoral breast augmentation
10 years previously. A ter the augmentation, she had two children; during each
pregnancy, she had signi cant breast volume increase and then postpartum atrophy.
She reported that a ter each pregnancy, her nipple location appeared to be lower,
although the subpectoral implants stayed in a relatively high position. She disliked
what she perceived as breast “droopiness” and in particular that her NACs pointed
downward. The patient was happy with her implant size and her appearance in her
clothes. She wanted only to have the breast skin reshaped and her nipples placed in
a more appropriate position.
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ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
On examination o the patient, it is obvious that the implants have stayed in a rela-
tively normal position, but the NACs have rotated in eriorly below the maximal
point o projection o the breast implants. Her IMFs are stable and require no ad-
justment. The superior poles o the breasts are symmetrical, and the implants are o
appropriate base diameter. The NACs are at symmetrical levels at the bottom o the
breast mounds. She exhibits no chest wall abnormalities.
ANALYSIS O F THE PRO BLEM
This patient is typical o many individuals who had a subpectoral breast augmen-
tation at a young age and who developed breast ptosis over time, especially a -
ter pregnancy. Except or the in eriorly displaced NACs and the lower pole o the
breast hanging o the implants, this patient has had a stable result rom her aug-
mentation over the last 10 years. This patient represents a typical problem with get-
ting subpectoral implants: when the patient ages or has multiple pregnancies, the
implants do not descend when the breasts become ptotic. There are, however, many
well-known bene ts to submuscular placement. Because the patient is happy with
her breast volume and there is no indication o anything being wrong with the im-
plants, isolated skin recontouring with nipple relocation is a reasonable approach.
RECOMMENDED SOLUTION TO THE PROBLEM
Per orming an inverted-T mastopexy with a short horizontal component
Releasing the in erior capsule o the breast implant
Maintaining her original breast implants

Chapter 19 • Ptosis in Previously Augmented Breasts

331
TECHNIQ UE
Based on preoperative markings, a vertical mastopexy pattern with a short hor-
izontal-T was deepithelialized. Through the vertical component, an incision was
carried down through the breast tissue and the capsule. The implant was retracted
superiorly to allow the capsule to be seen along the IMF. The patient had a very
thin capsule, which was incised with a cautery along the IMF area. No other cap-
sule work was done on either side, and the patient was placed in an upright posi-
tion to veri y proper location o the breast implant. Next, based on the preopera-
tive markings, tailor-tacking o the mastopexy markings was per ormed to con rm
the appearance. The nipple was marked with a 42 mm nipple marker, and a vertical
ellipse was deepithelialized with a short transverse component. The vertical deepi-
thelialized area was closed over the implant with a running 3-0 Vicryl suture, and
the mastopexy was closed in a vertical manner with a horizontal component. Be-
ore closure, the implant pocket was irrigated with antibiotic solution; however, the
implant itsel was not removed rom its subpectoral position.
Capsule

Part II: Problems in Augmentation Mammaplasty
332
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown preoperatively and then postoperatively at 8 months, at
2 years, and again at 5 years. Both the short- and long-term photos show very sta-
ble results. Interestingly, when comparing her preoperative photos with her postop-
erative results, it looks like her breasts became larger over time; this is a secondary
e ect o the in erior capsulotomy, which allowed the implants to drop and allowed
better positioning o the NACs. Looking at the patient’s body habitus and at her
abdomen be ore and a ter surgery, there does not appear to be signi cant weight
gain; there ore this change in appearance cannot be attributed to overall weight
gain. The apparent increase in breast volume probably indicates that once the lower
capsule was incised and the implant dropped, it was not being compressed in the
submuscular space. Her 5-year postoperative photos show that she has maintained
a stable result with good positioning o her NACs and adequate projection.
Preoperative
8 months postoperatively
2 years postoperatively
5 years postoperatively

Chapter 19 • Ptosis in Previously Augmented Breasts

333
2 years postoperatively
5 years postoperatively
Preoperative
8 months postoperatively

Part II: Problems in Augmentation Mammaplasty
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TEACHING PO INTS
This patient demonstrates that implants do not necessarily have to be changed at
the time o a secondary augmentation/mastopexy. A vertical combined with a short-
T provides proper skin envelope adjustment. The act that the original capsule rom
the prior augmentation was essentially le t untouched, except or the lower pole
capsulotomy, may have contributed to the long-term stable result in this patient.
BIBLIO GRAPHY
Calvert JW, Dickinson BP, Patel A, et al. Lateral breast f ap with superomedial pedicle breast li t. Aes-
thet Surg J 31:658-666, 2011.
Colwell AS, Driscoll D, Breuing KH. Mastopexy techniques a ter massive weight loss: an algorithmic
approach and review o the literature. Ann Plast Surg 63:28-33, 2009.
Dickinson BP, Handel N. Approaching revisional surgery in augmentation and mastopexy/augmenta-
tion patients. Ann Plast Surg 68:12-16, 2012.
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.
Gurunluoglu R, Sacak B, Arton J. Outcomes analysis o patients undergoing autoaugmentation a ter
breast implant removal. Plast Reconstr Surg 132:304-315, 2013.
Hickman DM. Application o the Goes double-skin peri-areolar mastopexy with and without im-
plants: a 14-year experience. J Plast Reconstr Aesthet Surg 64:164-173, 2011.
Hönig JF, Frey HP, Hasse FM, et al. In erior pedicle autoaugmentation mastopexy a ter breast implant
removal. Aesthetic Plast Surg 34:447-454, 2010.
Mestak J, Sukop A, Mestak O. Use o deepithelialized f ap in mammoplasties: simple method with ex-
cellent results. Aesthetic Plast Surg 35:1106-1011, 2011.
Paydar KZ, Kohan E, Hansen SL, et al. Long-term e ects o breast aging in patients undergoing ex-
plantation: analysis o breast aesthetics rom be ore augmentation to a ter explantation. Ann
Plast Surg. 2013 Mar 11. [Epub ahead o print]
Zienowicz RJ, Karacaoglu E. Augmentation mammaplasty by reverse abdominoplasty (AMBRA).
Plast Reconstr Surg 124:1662-1672, 2009.

19d Conversion to Subglandular Pockets
With Periareolar Mastopexy
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 48-year-old woman had subpectoral saline implants placed through periareo-
lar incisions 22 years previously. She had multiple pregnancies, with signi cant
enlargement o her breasts and secondary involution a ter each pregnancy. She re-
ported that her breasts sustained progressive ptosis over time, with the saline im-
plants staying elevated in the subpectoral pocket. She requested elevation o her
breasts as well as increased volume. She also disliked and requested correction o
the wide separation o her breasts with the lack o so t tissue in the sternal area.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
Evaluation o the patient’s chest wall reveals a slight pectus excavatum. She has
ptosis with palpable high-riding submuscular implants. The breast tissue is rotated
down over the implants, and the NACs are just slightly below the plane o the IMF.
The NAC distance to the clavical is excessive; however, there is no bottoming out
o the breasts, and the distance rom the areola to the IMF is only 6 cm. The breasts
have a very narrow base diameter, which contributes to the wide sternal separation.
There is approximately 3 cm o breast tissue over the muscle.
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Part II: Problems in Augmentation Mammaplasty
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ANALYSIS O F THE PRO BLEM
This patient’s situation is typical o patients who have had submuscular implants
placed at an early age and then had multiple pregnancies and associated weight
gains and losses. The original saline submuscular implants maintain a relatively
high position because the pectoral muscle acts as an internal bra. Over time the
breast tissue migrates down over the pectoralis muscle, creating ptosis and the typi-
cal contour seen in this patient. A ter giving birth, many women undergo signi cant
atrophy o breast tissue, which exaggerates the occurrence o ptosis. Also, although
the exact size is unknown, the patient’s original breast implants have a very narrow
base diameter, which creates the wide sternal separation.
RECOMMENDED SOLUTION TO THE PROBLEM
Repositioning o the NACs through periareolar mastopexy
Closure o the original submuscular pocket
Removal o the submuscular implants and placing the proper base diameter gel
implants in a subglandular position
TECHNIQ UE
Overlay shows the location o the high-riding subpectoral implant. Through an
in erior periareolar incision, dissection was made and continued down to the in e-
rior lateral margin o the pectoralis major muscle. An incision was made between
the lateral edge o the pectoralis muscle and the capsule overlying the implant. The
original saline implants were removed. The anterior capsule o the submuscular im-
plant was excised, and tacking sutures were placed deep to the muscle or closure
o the submuscular pocket. A subglandular pocket was created over the pectoralis
muscle and the remnant o the anterior capsule sitting laterally. Sizers were used to
con rm that the pocket dissection was adequate, then appropriately based diameter
implants were inserted. One o the goals o this secondary procedure was to reduce
the wide sternal separation that this patient had preoperatively.

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PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS

Early and late postoperative photos show maintenance o ptosis correction as well
as good contour and shape o the breasts. At 5-year ollow-up, the NACs are in
proper position, with reasonable periareolar scars. Placement o implants with a
proper base diameter has corrected the original wide sternal separation o the pa-
tient’s breasts. Placing the implants in the subglandular pocket allowed the im-
plants to descend with the breasts over time. One o the limiting actors o submus-
cular implants is that they tend not to descend in many patients, because the muscle
acts like an internal bra.

Part II: Problems in Augmentation Mammaplasty
338
TEACHING PO INTS
Using implants with the proper base diameter is critical. Converting the implants
rom submuscular to subglandular can be a good solution in this group o patients,
as long as there is adequate breast tissue. A periareolar mastopexy can only give the
breasts a limited li t but is excellent or NAC repositioning.
BIBLIO GRAPHY
Araco A, Araco F, Sorge R, et al. Sensitivity o the nipple-areola complex and areolar pain ollowing
aesthetic breast augmentation in a retrospective series o 1200 patients: periareolar versus sub-
mammary incision. Plast Reconstr Surg 128:984-989, 2011.
Bogdanov-Berezovsky A, Pagkalos VA, Krieger Y, et al. Burying the knot in periareolar mastopexy.
Aesthetic Plast Surg 37:851-853, 2013.
Cannon CL III, Lindsey JT. Conservative augmentation with periareolar mastopexy reduces compli-
cations and treats a variety o breast types: a 5-year retrospective review o 100 consecutive pa-
tients. Ann Plast Surg 64:516-521, 2010.
Goes JC, Bates D. Periareolar mastopexy with FortaPerm. Aesthetic Plast Surg 34:350-358, 2010.
Gonzalez R. The PAM method—periareolar augmentation mastopexy: a personal approach to treat
hypoplastic breast with moderate ptosis. Aesthet Surg J 32:175-185, 2012.
Mu D, Luan J, Mu L, Xin M. The relationship between the thickness o de-epithelialization and oc-
currence o sebaceous cysts at the incision site a ter mastopexy and reduction mammaplasty. Ann
Plast Surg 65:389-390, 2010.
Rancati A, Nava M, Tessari L. Simultaneous augmentation and periareolar mastopexy: selecting the
correct implant. Aesthetic Plast Surg 34:33-39; discussion 40-41, 2010.
Stutman RL, Codner M, Mahoney A, Amei A. Comparison o breast augmentation incisions and com-
mon complications. Aesthetic Plast Surg 36:1096-1104, 2012.

19e Circumareolar Mastopexy to Correct Ptosis
and Other Deformities After Augmentation
n ea l h a n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 46-year-old woman had multiple complaints rom previous breast augmenta-
tion in her early thirties. At that time, she underwent augmentation mammaplasty
with subpectoral placement o smooth saline implants through a periareolar inci-
sion. The patient was never happy with her outcome and thought that the result
urther deteriorated over time. By the time o presentation, she was extremely dis-
satis ed with the appearance o her breasts, and elt compelled “to do something”
to improve her appearance. Her chie concerns were that her breasts had an unnat-
ural appearance and that they were “droopy,” asymmetrical, and excessively rm.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
Physical examination reveals the patient had previously undergone bilateral sub-
pectoral augmentation mammaplasty through periareolar incisions, which are
well-healed. The scar on the le t side is retracted, causing a deep depression o the
in erior periareolar area, which is especially noticeable with the patient standing
upright. The breasts are ptotic; rom the sternal notch, the right nipple measures
26 cm and the le t nipple 27 cm. The IMFs are abnormally low rom descent o the
implants. There is a double-bubble de ormity on the right side. Both breasts are
rm with Baker grade III capsular contracture, and they are spherically de ormed,
with excessive upper pole ullness.
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Part II: Problems in Augmentation Mammaplasty
340
The IMFs are uneven, with the right IMF approximately 2 cm lower than the le t
IMF. The areolae are asymmetrical: the right areola measures 4 cm in diameter, and
the le t areola 5.5 cm in diameter.
ANALYSIS O F THE PRO BLEM
This patient had a constellation o abnormalities a ter undergoing breast augmen-
tation 15 years earlier. To the patient, her breasts were simply “unattractive”; how-
ever, it was actually a combination o speci c, identi able anatomic abnormalities
that contributed to the poor overall aesthetic outcome. The patient had signi cant
capsular contracture, which caused rmness, spherical de ormity, and excessive up-
per pole ullness. She also had breast ptosis. Ptosis is usually de ned as descent o
the nipple below the IMF; however, in this case, the patient had abnormally low
IMFs rom in erior malposition o the implants, which distorted the location o the
nipples in relation to the IMFs. This combination o contracture, in erior implant
malposition, and glandular ptosis resulted in a waterfall deformity, in which the
breast tissues cascade over the underlying encapsulated implant. The patient also
had asymmetrical nipple position, with her le t nipple approximately 1 cm lower
than her right nipple, and asymmetrically sized areolae, with the le t areola notice-
ably larger in diameter than the right areola. In addition, she had a retracted, teth-
ered periareolar scar on the le t side, resulting in an in ra-areolar depression. A
custom, combined surgical approach designed to address each o these speci c ana-
tomic abnormalities, was proposed.
RECOMMENDED SOLUTION TO THE PROBLEM
Removing both o the saline implants
Per orming bilateral total capsulectomy
Converting the implants to virgin submammary pockets
Per orming bilateral eccentric periareolar mastopexies
Inserting cohesive silicone gel implants
Revising the retracted le t periareolar scar

Chapter 19 • Ptosis in Previously Augmented Breasts

341
TECHNIQ UE
The patient is shown immediately be ore surgery, with the skin markings in place;
asymmetrical nipple position is noted. The areolae were elevated bilaterally, so that
the top, or 12 o’clock position, o each areola alls along the breast meridian 21 cm
rom the sternal notch. Eccentric periareolar mastopexy incisions were designed on
the le t breast. The incisions were made and the area in between deepithelialized.
The wound was deepened in eriorly, through the breast parenchyma beneath the
areola, using the previous periareolar scar; this resulted in wide exposure o the
anterior scar capsule, which was then dissected away rom overlying breast and
muscle.

Part II: Problems in Augmentation Mammaplasty
342
A capsulotomy incision was made, exposing a saline- lled implant that was easily
removed. The anterior wall o the contracted capsule was dissected o the overly-
ing pectoral muscle, and the posterior capsule dissected o the underlying chest
wall muscles and ascia; the capsule was removed en bloc.

Chapter 19 • Ptosis in Previously Augmented Breasts

343
The pectoralis major muscle was separated rom the overlying parenchyma to cre-
ate a new submammary pocket. Once the muscle was adequately reed, it was re-
placed in its normal anatomic position and sutured to the adjacent chest wall with
a series o interrupted gure-o -eight 2-0 PDS sutures. A sizer was inserted, the
wound edges approximated with staples, and the patient placed in the sitting posi-
tion to assess the new contours o the breast and to ensure that the new subglan-
dular pocket was adequately dissected in all dimensions. A moderate plus round
smooth 325 cc silicone gel implant was inserted into the subglandular pocket and
the deep layers closed. A periareolar purse string 0 Prolene suture was placed; a ter
the opening or the areola was reduced to the desired diameter o 3.5 cm, the knot
was tied and buried. The resulting shape o the revised breast and the newly recon-
gured NAC is seen a ter the purse-string suture was tightened and tied; the wound
edges were approximated with skin staples immediately be ore the nal skin clo-
sure. Similar steps were carried out on the right side.

Part II: Problems in Augmentation Mammaplasty
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PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient’s appearance is depicted
18 months a ter the revision surgery. She is
very satis ed with the result. Contracture
has been completely eliminated and is now
Baker grade I bilaterally, the ptotic water-
all de ormity has been ully eliminated,
and the double-bubble on the right side
has been e aced. The nipples and IMFs
are symmetrical, and the areolar diameters
equivalent. The depressed, retracted le t
periareolar scar has been eliminated. The
patient no longer considers her breasts to
be ugly or unnatural looking.

Chapter 19 • Ptosis in Previously Augmented Breasts

345
TEACHING PO INTS
This patient presented with ptosis, contracture, and multiple other postsurgical de-
ormities a ter breast augmentation 15 years earlier. The patient underwent a com-
bined corrective operation: the central procedure was a mastopexy to reposition
the NAC at a higher level, to reduce areolar diameter, and to improve areolar sym-
metry. The critical aspect o mastopexy in previously augmented patients is preser-
vation o the blood supply to the nipples. When breast augmentation is per ormed,
creation o the pocket necessarily results in division o many o the per orators sup-
plying the gland and the overlying skin and nipple. As in this case, the long-term
presence o implants invariably results in tissue thinning, atrophy, and stretching,
which urther compromises the blood supply. It is important to consider many ac-
tors when designing a secondary mastopexy in a previously augmented patient,
including the position o the implant in relation to the muscle, the location o the
previous surgical scars, and the thickness o the so t tissue envelope surrounding
the breast implant. To achieve the desired result with minimal urther disruption o
blood supply to the skin f ap and nipple, it is also important to consider the role o
capsular contracture, to decide whether capsulotomy or capsulectomy is necessary,
and to determine how aggressive the capsule surgery should be.
In this patient, because the previous augmentation incision was made beneath the
areola, the revision was per ormed through an in erior areolar scar. This preserves
the superior pedicle and its associated blood vessels. The selection o a more con-
servative circumareolar mastopexy, compared with a more aggressive vertical or
Wise pattern mastopexy, urther promotes the preservation o blood supply to the
nipple and skin f aps.
Typically, leaving the implant in the subpectoral position would probably better
preserve the per orators arising through the pectoral muscle. However, in this pa-
tient, we decided to convert rom the subpectoral to the submammary position,
which was prudent because the nipple was being raised only a short distance and
because the f aps were thick, with a pinch test greater than 3 cm. Converting to the
submammary position has at least three advantages: it eliminates any contour ab-
normalities that the retained anterior capsule might cause, allows better redraping
o the so t tissues to acilitate the correction o ptosis, and reduces the risk o recur-
rent contracture rom aggressive capsulectomy and pocket conversion.
BIBLIO GRAPHY
Collis N, Sharpe DT. Recurrence o subglandular breast implant capsular contracture: anterior versus
total capsulectomy. Plast Reconstr Surg 106:792-797, 2000.
Dickinson BP, Handel N. Approaching revisional surgery in augmentation and mastopexy/augmenta-
tion patients. Ann Plast Surg 68:12-16, 2012.
Dinner MI, Artz JS, Foglietti MA. Application and modi cation o the circular skin excision and
pursestring procedures. Aesthetic Plast Surg 17:301-309, 1993.

Part II: Problems in Augmentation Mammaplasty
346
Handel N. Secondary mastopexy in the augmented patient: a recipe or disaster. Plast Reconstr Surg
118(7 Suppl):152S-163S; discussion 164S-165S, 166S-167S, 2006.
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.
Médard 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.
Spear S. Augmentation/mastopexy: “surgeon, beware.” Plast Reconstr Surg 112:905-906, 2003.

19f Explantation and Wise Pattern Mastopexy
in a Patient With Prior Augmentation-Mastopexy
n ea l h a n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 37-year-old woman had a primary breast augmentation through an in ra-
mammary incision at age 24. Approximately 8 years later, at age 32, she returned
to her plastic surgeon complaining o ptosis. The ptosis was treated by removal and
replacement o her implants with signi cantly larger silicone implants and bilateral
circumareolar mastopexy. Initially, she was happy with her larger implants; how-
ever, a ter several years, she thought that her breasts were too large. She was also
concerned about sagging, breast rmness, and “stretched out” areolae. The patient
requested surgery to address each o these concerns.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient is o medium height and build. She had previously undergone bilat-
eral subglandular augmentation through long in ramammary scars, which are well
healed. The patient also has widened periareolar mastopexy scars on both breasts.
347

Part II: Problems in Augmentation Mammaplasty
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Her breasts appear much too large or her rame, and are spherically de ormed,
rm, and slightly tender to palpation, with Baker grade III capsular contracture.
The right nipple is 27 cm rom the sternal notch, and the le t nipple is 28 cm rom
the notch. The areolae are dilated, measuring 7 to 8 cm in diameter on both sides.
ANALYSIS O F THE PRO BLEM
This patient presented with excessively large breasts, moderately severe capsular
contracture, and a history o previous bilateral circumareolar mastopexies. Her de-
sire was to have signi cantly smaller, upli ted breasts and smaller NACs. Based on
the thickness o the so t tissue envelope as assessed by pinch test, it appeared that
the patient would have adequately sized breasts without implants. Her nipples were
5 to 6 cm in erior to the level o the IMFs. The need to elevate the nipples a signi -
cant distance, and the patient’s desire to permanently reduce her areolar diameter,
led to the recommendation o a Wise pattern mastopexy. We thoroughly discussed
with her the potential risks o additional surgery, with emphasis on the possibility
o compromised circulation to the nipples and/or skin f aps.
RECOMMENDED SOLUTION TO THE PROBLEM
Removing both silicone gel implants
Per orming a posterior capsulectomy
Per orming an anterior “checkerboard” capsulotomy
Carrying out bilateral Wise skin pattern mastopexies, preserving both the in e-
rior and superior pedicles to the nipples

Chapter 19 • Ptosis in Previously Augmented Breasts

349
TECHNIQ UE
The patient’s breasts were marked immediately be ore surgery; the new location or
the nipples was marked along the breast meridian 22 cm rom the sternal notch.
The top o the keyhole pattern, at the proposed 12 o’clock position o the areola,
was drawn 2 cm above the new nipple location to provide a 4 cm diameter areola.
The limbs o the keyhole were made 5 cm in vertical height and were drawn to di-
verge just enough that they would resect all o the pigmented areolar tissue and the
old circumareolar scar.

Part II: Problems in Augmentation Mammaplasty
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The original IMF scar and the circumareolar mastopexy scar were marked. The
42 mm circular, cookie cutter template was used to mark the new areolar circum-
erence; care was taken to center the nipple within the areola. The pedicle was
deepithelialized, leaving as much dermis behind as possible, both to promote cir-
culation to the NAC and to maintain the integrity o the in erior and superior ped-
icles. The incision was deepened through the dermis on both sides o the vertical
pedicle, and the medial and lateral mastopexy f aps were elevated just beneath the
dermis in the mastectomy skin f ap plane. The wound was deepened and the breast
parenchyma dissected o the anterior capsule in the lower outer quadrant. Part o
the anterior capsule was resected, exposing the silicone gel implant, which was re-
moved without di culty.

Chapter 19 • Ptosis in Previously Augmented Breasts

351
The in erior pedicle was approximately 1 cm in thickness; the scar tissue lining the
undersur ace o the pedicle was le t undisturbed, to preserve as much blood supply
as possible. The posterior scar tissue capsule, which was lining the anterior sur ace
o the pectoral muscle and adjacent chest wall, was resected to create a raw tissue
sur ace, to promote adherence o the f aps, and to eliminate any potential “dead
space.” The anterior scar tissue capsule, which was quite thickened and contracted,
was le t in situ but was scored in checkerboard ashion to create raw sur aces to
heal to the subadjacent chest wall. A 7 mm f at Jackson-Pratt silicone drain was in-
serted into the pocket to evacuate any blood or serum that might collect, promot-
ing secure attachment o the breast f aps to the chest wall. The nipple was relocated
into its new position atop the keyhole, the medial and lateral mastopexy f aps were
brought into approximation with one another, and the nal layered closure was
completed. The patient had an unevent ul postoperative course.

Part II: Problems in Augmentation Mammaplasty
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PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS

The patient’s appearance is depicted 1 year
a ter revision surgery. She is satis ed with
the size, symmetry, and overall appearance
o her breasts. Ptosis has been corrected
and areolar diameter signi cantly reduced.
The patient’s smaller, upli ted breasts are
much more harmonious with the rest o her
gure. The le t breast has a subtle “boxy
appearance,” but this does not bother the
patient.

Chapter 19 • Ptosis in Previously Augmented Breasts

353
TEACHING PO INTS
This previously augmented patient presented with ptosis, contracture, and exces-
sively dilated areolae. She wanted a reduction in breast size combined with an up-
li t. In her particular case, long in ramammary scars and circumareolar scars were
present bilaterally. Her implants were very large and in the subglandular position,
which contributed to stretching, thinning, and atrophy o the parenchyma. All o
these actors, including her previous surgical scars, and the impaired circulation to
the nipple and skin, greatly increase the risk o ischemic complications a ter mas-
topexy. There ore her operation was designed to minimize urther disruption to
the arterial inf ow or the venous drainage o the nipple and mastopexy f aps. The
nipple was repositioned on a vertical superior and in erior pedicle o dermis and
breast parenchyma. The thickest possible layer o dermis was le t to prevent injury
to the subdermal plexus. To maintain blood supply, the anterior scar tissue capsule
on the undersur ace o the pedicle was le t undisturbed. To provide a raw tissue
sur ace to which the overlying f aps would attach, the posterior scar tissue capsule
on the anterior sur ace o the pectoral muscle and adjacent chest wall was removed.
To disrupt blood supply as little as possible, the anterior capsule was not resected;
however, a checkerboard capsulotomy was per ormed to create raw tissue sur aces
designed to heal to the adjacent underlying chest and also to allow the tissues to
reely redrape, assuring an aesthetically attractive breast contour.
In a previously augmented patient, it is always perilous to per orm mastopexy and
capsule surgery, either with or without implant replacement. The risks are even
greater in a case such as this in which the patient has undergone previous masto-
pexy. At all times, the surgeon must be mind ul o maintaining adequate circulation
to the nipple and skin f aps.
A ew principles are help ul to avoid complications. The least invasive mastopexy
that will achieve the desired outcome should be selected. Initial skin excision should
be conservative, to avoid excessively tight closure; additional skin can always be
removed at the end o the procedure, a ter the f aps have been approximated. The
thickest and widest possible pedicle should be preserved. The location o any previ-
ous surgical incisions, which may have partially or completely divided blood f ow
through the proposed pedicle (or pedicles), must be considered. The amount o
capsule surgery per ormed—capsulotomy, capsulectomy, or capsuloplasty—should
be moderated to avoid urther thinning o the tissues. I a new implant is being in-
serted, care should be taken that the implant is not so large that it places excessive
tension on the suture lines or compresses the pedicles, thus compromising venous
drainage. When in doubt about whether there is adequate circulation to the nipple
or skin f aps, insertion o the implant should be postponed until all areas have suc-
cess ully healed, and then it should be per ormed as a delayed procedure.

Part II: Problems in Augmentation Mammaplasty
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BIBLIO GRAPHY
Dickinson BP, Handel N. Approaching revisional surgery in augmentation and mastopexy/augmenta-
tion patients. Ann Plast Surg 68:12-16, 2012.
Handel N. Secondary mastopexy in the augmented patient: a recipe or disaster. Plast Reconstr Surg
118(7 Suppl):152S-163S; discussion 164S-167S, 2006.
Spear S. Augmentation/mastopexy: “surgeon, beware.” Plast Reconstr Surg 112:905-906, 2003.
Spear SL, Low M, Ducic I. Revision augmentation mastopexy: indications, operations, and outcomes.
Ann Plast Surg 51:540-546, 2003.
Stevens WG, Spring M, Stoker DA, et al. A review o 100 consecutive secondary augmentation/masto-
pexies. Aesthet Surg J 27:485-492, 2007.

20a Lipomodeling and IMF Fixation to Correct
Asymmetry After Failed Breast Implants
Emma n u el Del ay
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 48-year-old patient presented or secondary correction o severe sequelae rom
the ailure o multiple breast implant augmentations and mastopexies.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
A ter numerous procedures ailed, the patient does not want new implants. Rather,
she is requesting the simplest procedures with limited risks.
ANALYSIS O F THE PRO BLEM
The patient has lost de nition o her IMF and has asymmetry between the breasts.
The IMF needs to be reestablished on the le t breast, and both breasts need to have
at gra ting to provide a more natural appearance and better symmetry.
c h a Pt Er 2 0
ASYMMETRIES IN PREVIOUSLY
AUGMENTED BREASTS
355

Part II: Problems in Augmentation Mammaplasty
356
RECOMMENDED SOLUTION TO THE PROBLEM
Multiple lipomodeling sessions to improve the contour and symmetry o the
breasts
IMF correction with f ap xation to the thoracic wall
TECHNIQ UE
The patient was treated with one lipomodeling session with 250 cc to the le t breast
and 280 cc to the right breast, in addition to xation o the IMF. The f ap was
marked, and then incised and deepithelialized. Incision o the upper part o the f ap,
and nally f ap xation to the thoracic wall, are shown.
The f ap xation to the thoracic wall was per ormed in two layers to obtain a good
de nition o the IMF.

Chapter 20 • Asymmetries in Previously Augmented Breasts

357
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
Three months a ter the procedure, the restored IMF was evident. Four months
later, a second session o lipomodeling—le t breast 310 cc, right breast 270 cc—
improved shape and symmetry a little more. The patient is very happy with the
result and can now wear aesthetic bras. The results 2 years a ter the last session
are shown.
TEACHING PO INTS
Rebuilding the IMF is the rst step o this type o reconstruction. A ter that, lipo-
modeling is per ormed in a multilayered ashion, starting rom the deep plane and
moving to the super cial plane. Fat must be injected in ne tunnels and in a con-
sistent ashion to avoid necrosis. Fat trans er should be stopped when the recipient
site is saturated, when at is injected by another incision. Then, i you need more
volume, you can plan another session or additional at trans er.
I some brous bands are present a ter the scar heals, you should rupture these
strings and adhesions with the tip o a 14-gauge trocar.

Part II: Problems in Augmentation Mammaplasty
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BIBLIO GRAPHY
Delay E. Lipomodeling o the reconstructed breast. In Spear SE, ed. Surgery o the Breast: Principles
and Art, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2006.
Delay E. Reconstruction o breast de ormities. In Coleman SR, Mazzola RF, eds. Fat Injection: From
Filling to Regeneration. St Louis: Quality Medical Publishing, 2009.
Delay E, Garson S, Toussoun G, Sinna R. Fat injection to the breast: technique, results, and indica-
tions based on 880 procedures over 10 years. Aesthet Surg J 29:360-376, 2009.
Delay E, Moutran M. Fat gra ting to the breast. In Nahai F, ed. The Art o Aesthetic Surgery, vol III,
2nd ed. St Louis: Quality Medical Publishing, 2011.
Ho Quoc C, Sinna R, Gourari A, La Marca S, Toussoun G, Delay E. Percutaneous asciotomies and
at gra ting: indications or breast surgery. Aesthet Surg J 33:995-1001, 2013.

20b Asymmetrical Mastopexies, Unilateral Volume
Reduction, and Implant Replacement
Ja c k Fish er
PATIENT HISTO RY LEADING TO SPECIFIC BREAST PRO BLEM
The patient was seen at age 26, 6 years a ter having undergone an augmentation
mastopexy. At her original procedure at age 20, her primary complaint was asym-
metry: not only was her le t breast smaller, but it also sat higher than her right
breast. Early postoperative photos a ter her original augmentation show continued
asymmetry, although it had improved because a larger implant was placed on the
le t side. The implants appeared to be sitting high, and there was a degree o breast
ptosis on the right that was greater than that o the le t. The patient subsequently
lost a signi cant amount o weight; when seen at age 26, her breasts were slightly
less asymmetrical but still had high-riding implants with overprojection o the su-
perior pole o the breasts. The implants were subglandular. She requested improved
symmetry and better shape to her breasts.
Age 26
Age 20
359

Part II: Problems in Augmentation Mammaplasty
360
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
Physical examination reveals slight asymmetry o the NACs, with the right nipple
24 cm rom the clavicle in the breast midline plane and the le t nipple 22.5 cm rom
the clavicle. The le t breast volume is slightly smaller, and both NACs are sitting at
the bottom o the breast mounds. The right NAC diameter is also slightly greater
than that o the le t. Also, the superior poles o both breasts are overprojected,
there ore creating the appearance o high-riding implants. The implants are in the
subglandular plane.
ANALYSIS O F THE PRO BLEM
Weight loss or weight gain over time can have a signi cant impact on a previous
breast augmentation. In this case, one o the main reasons or the original augmen-
tation was breast asymmetry. However, although using di erent size implants may
improve volume asymmetry, this usually does not correct the other components o
patients with asymmetrical breasts. In this case, the breast on the right was more
ptotic, especially at age 20; in addition, sometimes using two di erent size implants
can create the appearance o greater asymmetry by increasing superior ullness on
the smaller side. With the patient’s weight loss over 6 years, the ptotic asymmetry
was somewhat less; possibly the larger implant on the le t side caused the le t breast
to gradually drop more than the the right breast. However, as shown on a lateral
view, the patient’s upper poles are still overprojected, which tends to make the
NACs appear low and to point downward.
The key to improving this patient’s asymmetry was doing some type o mastopexy
to improve the nipple-areolar position and to place the implants in a more natural
location. Also, as a result o trying to correct volume asymmetry at the time o mas-
topexy, the surgeon had an opportunity to per orm selective tissue removal, so sim-
ilar volume implants could have been used. Symmetry is more likely to be created
by using the same size or closely sized implants.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the original subglandular implants
Periareolar mastopexy on the less ptotic le t side
Vertical (with a short horizontal) mastopexy on the right breast
Removal o a small amount o breast tissue on the right to improve volume
symmetry
Placement o new subglandular silicone gel implants: 250 cc moderate pro le on
the right side and 275 cc moderate plus pro le on the le t side

Chapter 20 • Asymmetries in Previously Augmented Breasts

361
TECHNIQ UE
Both o the patient’s implants were removed using the mastopexy incision sites. On
the le t side, the lower portion o the periareolar mastopexy was used to remove the
subglandular implant. On the right side, where a vertical mastopexy had been per-
ormed, the implant was removed by going through the vertical plane in the breast
tissue down to and through the capsule. Di erent size temporary sizers were used
to select the implant size. A small amount o medial and lateral breast tissue was
removed rom both sides o the vertical incision o the right breast. Even with some
tissue removal, we elected to put a slightly larger implant on the le t side based on
the volumes that the sizers indicated would create the best symmetry. A smooth
moderate plus 275 cc gel implant was inserted in the le t subglandular pocket, and
a moderate 250 cc device on the right.
Area to be
deepithelialized
varies

Part II: Problems in Augmentation Mammaplasty
362
The periareolar mastopexy on the le t side was closed with a permanent suture us-
ing the technique described by Hammond. The right side was closed in essentially a
circumvertical method, also described by Hammond. Employing a slight variation,
we adjusted the apical suture based on the tightness o the closure. The shorter the
in ramammary scar, the longer the vertical scar, and vice versa. This minor adjust-
ment allowed proper tension at the apical suture site. On secondary cases, this also
minimizes the creation o an excessively long vertical scar.
Parallel markings allow adjustment of the apical suture

Chapter 20 • Asymmetries in Previously Augmented Breasts

363
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
This patient obtained signi cant improvement in both symmetry and shape. Using
the circumvertical mastopexy incision to remove additional skin and some breast
tissue on the right side made the right side look more like the le t. With the periare-
olar mastopexy, only limited skin removal was needed on the le t side. The proce-
dure also created a more natural superior pole to the breasts. In a breast with ex-
cessive upper pole ullness or convexity, lowering the point o maximal projection
to the lower portion o the breast usually creates a more natural shape.

Part II: Problems in Augmentation Mammaplasty
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TEACHING PO INTS
The best chance to create symmetry is to per orm similar procedures on both sides
when possible. In this case, the removal o a limited amount o breast tissue on the
right side meant that implants o very similar volumes could be used. Also, a more
symmetrical surgical approach could be per ormed as a result o doing a periareo-
lar mastopexy on one side and a circumvertical mastopexy on the contralateral
side, which included a periareolar closure. A short horizontal component o skin
was removed on the right to create symmetry between the bottoms o the areolae
to the IMFs. I bilateral periareolar mastopexies were per ormed, it would have
been necessary to take a greater amount o skin on the right side; however, the right
breast might have appeared somewhat f atter, with less projection than the le t side.
In addition, bilateral periareolar mastopexies would not necessarily correct the dis-
parity between the amount o skin in the lower pole o the breast, where the right
side was greater than the le t. It is important to equalize the distances between the
NAC and the IMF on each side.
BIBLIO GRAPHY
Hammond DC. Short scar periareolar in erior pedicle reduction (SPAIR) mammaplasty. Plast Reconstr
Surg 103:890-901, 1999.
Hammond DC, Al onso D, Khuthaila DK. Mastopexy using the short scar periareolar in erior pedicle
reduction technique. Plast Reconstr Surg 121:1533-1539, 2008.
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.
Jacobson JM, Gatti ME, Scha ner AD, et al. E ect o incision choice on outcomes in primary breast
augmentation. Aesthet Surg J 32:456-462, 2012.
Yesilada AK, Sevim KZ, Sirvan SS, et al. Our surgical approach to treatment o congenital, develop-
mental, and acquired breast asymmetries: a review o 30 cases. Aesthetic Plast Surg 37:77-87,
2013.

C h a p t e r 2 1
EXPLANTATION
21a SIEF: Simultaneous Implant Exchange
With Fat Grafting
Da n iel a . Del Vec c h io
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 36-year-old woman had three previous breast augmentation procedures. In her
initial procedure 6 years earlier, she underwent submuscular breast augmentation
with silicone gel implants. Within 6 months she developed severe capsular contrac-
ture in the right breast. To treat this problem, she underwent implant exchange on
the right side with capsulotomy.
Shortly a ter this, she developed a recurrent capsular contracture and underwent
implant exchange with capsulectomy on the right side. Following this procedure,
the patient had recurrence o her right contracture, with implant malposition and
severe pain.
The patient was happy with her overall breast volume but was very unhappy with
her breast asymmetry and her pain and sought options or explantation.
This woman is a healthy, relatively thin nonsmoker with no signi cant medical is-
sues. She weighs 128 pounds. There is no amily history o breast cancer and no
medical history o breast disease. The size o the existing silicone gel implants is
300 cc.
365

Part II: Problems in Augmentation Mammaplasty
366
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has relatively good so t tissue coverage over her existing silicone gel
implants. There is a Baker II capsular contracture on the right breast, with the IMF
approximately 1 cm higher on the right and the le t. There is loss o so t tissue and
loss o roundness o the lower pole o the right breast compared with the le t. There
is a narrow 1 cm cleavage gap when the patient is ully relaxed with her arms not
pressed on her hips. Palpation o the right breast elicits pain along the lateral aspect
o the implant pocket.
ANALYSIS O F THE PRO BLEM
This patient demonstrates a common problem seen in capsule contracture a ter
breast augmentation—a relatively minor de ormity, but a signi cant and debilitat-
ing problem rom the patient’s perspective. A ter several attempts are made to treat
capsule contracture in a breast augmentation patient, the patient will o ten become
discouraged and ear that she will never have the result she had initially hoped or.
As Millard stated, “The more subtle the anatomic de ormity, the more di cult it is
to satis y the patient’s needs.”
Additional attempts at solving capsular contracture and achieving breast symmetry
are requently raught with ailure, and the patient becomes more and more dis-
couraged, eventually seeking explantation. In these patients, current explantation
options are limited to removing the implants and per orming a breast li t i neces-
sary. This is o ten not chosen by patients or by plastic surgeons, since it runs coun-
ter to the patient’s initial desire to have larger, uller breasts.
With the advent o success ul autologous at transplantation to the breasts, achiev-
ing volume increases o 200 to 300 cc reliably, the possibility now exists o simulta-
neously exchanging the volume o the breast implant or a volume o at.
In simultaneous implant exchange with at (SIEF), at can be transplanted in the
subcutaneous or “third space” o the breast while removing the breast implant and
allowing the pocket to collapse—all in one procedure.
Fat graft

Chapter 21 • Explantation

367
RECOMMENDED SOLUTION TO THE PROBLEM
Preoperative expansion o the subcutaneous space o the breast over the existing
implants
Fat transplantation in the third space o the breast
In the same operative session, removal o implants
In the same operative session, additional at transplantation to the subcutaneous
space o the breast once the implant has been removed
TECHNIQ UE
The patient underwent three-dimensional breast imaging to calculate total breast
volume be ore expansion. The total breast volume was 600 cc. Subtracting the vol-
ume o the breast implants (300 cc), the patient’s native breast tissue was calculated
at 300 cc.
Based on previous work demonstrating a 60% volume maintenance o transplanted
at to long-term volume, to replace a 300 cc breast implant with 300 cc o at, ap-
proximately 500 cc o at would be transplanted in each breast. Based on previous
work involving recipient site capacity, to success ully transplant 500 cc o at, the
recipient site should be at least the same volume, or 500 cc. There ore the patient’s
expansion goal volume was 500 cc o breast tissue. Adding this back to the implant
o 300 cc, the patient’s total breast volume during expansion would need to reach
800 cc.
The patient underwent 3 weeks o expansion using an external volume expander
device (Brava, Miami, FL).
She reached her goal volume and was brought to the operating room or surgery.
A ter installation o 6 L o tumescent solution into the patient’s thighs, f anks, and
abdomen, we removed a total o 3500 cc o lipoaspirate using custom 4 mm diam-
eter, 12-hole cannulas. This aspirate was allowed to decant at one times the orce

Part II: Problems in Augmentation Mammaplasty
368
o gravity, and the excess crystalloid and blood was removed. Next the at was
trans erred into 60 cc syringes and spun using a hand-crank centri uge at 40 G or
2 minutes. This maneuver removed an additional 30% o crystalloid rom this at
preparation. The additional crystalloid was then simply removed rom the syringes,
and at injection commenced in the breasts with the implant still in place.
STAGE I INjECTIO N
Using a 14-gauge needle 1 cm in erior to each IMF, a 14-gauge Coleman side-hole
cannula was attached to the same 60 cc syringes that were used to process at to
inject at into the breasts. Using gentle thumb pressure at the rate o 1 cc per sec-
ond, a “reverse liposuction” technique was employed to in ltrate the at in the sub-
cutaneous layers o the breast. Care was taken to keep the tip o the injection can-
nula distal to the implant at all times, thereby avoiding accidental puncture o the
implant.
A ter the rst stage o injection, the breast implants were removed by their original
IMF incisions. These incisions were made as small as possible to sa ely remove the
implant while avoiding a large subcutaneous incision where at could spill out. In-
spection o the breast implants revealed no trauma to the devices. Inspection o the
pockets revealed no inadvertent at injected into the implant pockets.
STAGE II INjECTIO N
A total o 390 cc o at was placed in the subcutane-
ous space o each breast be ore explantation. This
“worm’s-eye view” o the patient a ter stage I injec-
tion o the le t breast be ore implant removal dem-
onstrates the e ect o the transplanted at.
Following explantation, stage II injection o addi-
tional at was per ormed because the pressure in
the subcutaneous space o the breast was reduced
a ter removal o the breast implant. A total o 650
and 655 cc o at was placed into the right and le t
breasts, respectively.

Chapter 21 • Explantation

369
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 9 months a ter her nal procedure; improvement o her breast
asymmetry at the level o the IMF is evident. The volume de ciency o the lower
pole o the right breast has been corrected. Although she is a thin patient, there are
no donor site de ormities. Moreover, on examination, the breasts are so t and natu-
ral eeling. There is no pain on palpation o the breasts. The patient has been liber-
ated rom her implants, with no loss o volume or compromise on breast aesthetics.
Using three-dimensional imaging, the volume o the breasts postoperatively was
650 cc, which was slightly larger than the patient’s total breast volume preopera-
tively.

Part II: Problems in Augmentation Mammaplasty
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TEACHING PO INTS
In patients with breast implants, so t tissue and parenchymal thinning o the native
breast tissue overlying the implant is not uncommon. I explantation o the device
is contemplated and at transplantation is envisioned to replace the implant volume
with at, the quality o the recipient site should be care ully considered. O ten the
capacity o this recipient site is inadequate to hold the desired volume o at needed
to achieve the cosmetic result. In these instances, preexpansion using an external
volume expansion device is essential to achieve the desired goal in one operative
procedure.
Capsule contracture can be a devastating problem or both patient and surgeon.
Repeated e orts at treating capsular contracture can destroy so t tissue and de-
crease precious volume that is required to cover breast implants. There comes a
point, di erent or every individual, where explantation is desired by the patient
who cannot continue with breast implant revision. In such cases, simultaneous im-
plant exchange with at (SIEF) can be a viable option with proper surgical planning
and recipient site preparation. Fat transplantation or simultaneous implant ex-
change with at can be sa ely per ormed on thin patients.
BIBLIO GRAPHY
Del Vecchio DA. “SIEF”—simultaneous implant exchange with at: a new option in revision breast
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Del Vecchio D, Bucky LP. Breast augmentation using pre-expansion and autologous at transplanta-
tion: a clinical radiographic study. Plast Reconstr Surg 127:2441-2450, 2011.
Del Vecchio D, Rohrich RJ. A classi cation o at gra ting: di erent problems, di erent solutions.
Plast Reconstr Surg 130:511-522, 2012.
Khouri R, Del Vecchio D. Breast reconstruction and augmentation using pre-expansion and autolo-
gous at transplantation. Clin Plast Surg 36:269-280, 2009.
Khouri RK, Eisenmann-Klein M, Cardoso E, et al. Brava and autologous at trans er is a sa e and e -
ective breast augmentation alternative: results o a 6-year, 81-patient, prospective multicenter
study. Plast Reconstr Surg 129:1173-1187, 2012.
Tebbetts J. A system or breast implant selection based on patient tissue characteristics and implant-
so t tissue dynamics. Plast Reconstr Surg 109:1396-1409, 2002.
Yoshimura K, Asano Y, Aoi N, et al. Progenitor-enriched adipose tissue transplantation as rescue or
breast implant complications. Breast J 16:169-175, 2010.