Phẫu Thuật Thẩm Mỹ Vòng 1: Các Khái Niệm Và Kỹ Thuật (Aesthetic Breast Surgery)

180
Part II • Technique
The f beroptic retractor and monopolar insulated orceps (ASSI Corp., West-
bury, NY) used or dissection o the pocket are shown above. I use the double-
handled retractor on the le t or insertion o the implant.
The incision is made with a No. 15 blade through the skin and initial subcuta-
neous tissue. Further dissection is per ormed with the monopolar orceps. Pre-
viously I used blunt f nger dissection in the subglandular pocket, but I now a-
vor cautery dissection, which makes it easier to stay in the right plane. I like the
monopolar insulated orceps, because I can use them or dissection and, at the
same time, I can pinch and cauterize any vessels without having to change in-
struments. I believe that sharp dissection is best, but these orceps are also ar
better or providing me with an almost bloodless f eld.
Anesthesia
All breast augmentations in my practice are per ormed under ull general anes-
thesia, usually in my own surgical acility or sometimes in the hospital (because
o health or medical coverage issues or developmental de ormities). I have per-
ormed breast augmentation under local anesthetic but pre er a general anes-
thetic so that I can concentrate on the surgery without having to communicate
with the patient. I also f nd that the patient wakes up rom general anesthesia
without any prolonged drug e ects.
I inf ltrate the skin incision with 0.5% bupivacaine with 1/ 100,000 epineph-
rine. This maneuver alone has made the greatest di erence in alleviating post-
operative pain. Because I will excise the skin edges be ore f nal closure, I make
sure that this inf ltration extends well beyond the incision markings.
Technique
1
5A-3 Infiltration for
subglandular breast
augmentation
5B-3 Infiltration for
subpectoralbreast
augmentation

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Chapter 5 • Breast Augmentation
Pocket dissected
I use monopolar orceps to release the muscle medially toward the sternum. I
try to preserve the vessels that travel up into the subcutaneous tissue medially
as they come rom the internal mammary system around the sternum. The lat-
eral edge o the pectoralis muscle is shown elevated in the orceps on the right
breast. Dissection proceeds medially once the pectoralis minor is identif ed and
then le t undisturbed on the chest wall.
To f nd the right plane between the pectoralis major and minor muscles and to
avoid dissecting under the pectoralis minor, I release the pectoralis major mus-
cle laterally and in eriorly and elevate the muscle until I see the f lmy tissue be-
tween the muscles. The photo shows the lateral edge o the pectoralis muscle
on the right breast.
1
5A-4 Pocket
dissection for
subglandular breast
augmentation
5B-4 Pocket
dissection for
subpectoralbreast
augmentation

182
Part II • Technique
Whether I am dissecting in the subglandular plane or the subpectoral plane, I
will encounter the per orator (with its venae comitantes) that comes up into
the breast tissue through the pectoralis muscle. It almost always enters just above
the f th rib and medial to the breast meridian. The photo on the le t shows the
artery visible in a subglandular pocket entering the breast parenchyma as it
pierces the pectoralis muscle. The photo on the right shows the artery coming
just above the f th rib and entering the pectoralis muscle. The blood supply
comes rom the internal mammary system beneath the intercostal muscles. The
artery penetrates the intercostal muscles and then the pectoralis major muscle
just above the f th rib and just medial to the breast meridian.
When I am releasing the pectoralis muscle medially, it is clear that the muscle
(as described by Ian Taylor) also has J-shaped attachments to the anterior ribs.
These need to be released. One o the J attachments is shown above, between
the arrows.
1
5A-4 Pocket
dissection for
subglandular breast
augmentation
5B-4 Pocket
dissection for
subpectoralbreast
augmentation

It is important to release the in eromedial origins o the pectoralis major mus-
cle into the sixth rib. It is best to leave a cu o muscle in eriorly and carry the
release up toward the sternum. Close to the sternum the release is tapered so
that there is not a sharp demarcation. The release should not be carried medi-
ally up the sternal border.
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Chapter 5 • Breast Augmentation
Pocket dissected
When I used the shaped cohesive gel implant, I dissected a tight-f tting pocket
that exactly matched the size and shape o the implant. I painted povidone-
iodine on the posterior sur ace o the implant and placed the implant over the
skin, marking the outline on the skin or use as a guide. (I no longer use the
shaped implants.)
When I use a round textured implant, I also dissect a pocket just large enough
to receive the implant and ensure that no olds or ripples are present.
With all the smooth-walled implants, I make a pocket that will be slightly larger
than the chosen implant and ensure that the implant sits properly in the pocket
without any olding.
1
5A-5 Implant
insertion for
subglandular breast
augmentation
5B-5 Implant
insertion for
subpectoral breast
augmentation

184
Part II • Technique
I tend not to use sizers; I have been in practice long enough to be able to as-
sess size without them. Until a surgeon has this experience, however, sizers are
a good option.
I try not to dissect too ar superiorly under the pectoralis muscle
to help prevent the implant rom sliding upward postoperatively.
I use a smooth retractor (with outwardly curved edges to help prevent skin dam-
age) or implant insertion. The implants are soaked in povidone-iodine, and the
pocket is rinsed with a povidone-iodine/ bupivacaine mixture. Povidone-iodine
creates a slippery sur ace that makes the implants easier to insert and reduces the
level o Staphylococcus epidermidis. I do not change my gloves, but I make sure
that they are clean be ore handling the implants. We now use talc- ree gloves. (I
am concerned when I see surgeons changing their gloves right over the surgical
f eld be ore inserting implants, because I am sure that some o the talc and/ or
bacteria rom inside the gloves might get spread out over the surgical f eld.)
Be ore skin closure I cut away the skin edges, because I have o ten
damaged them slightly with the retractor. This maneuver has im-
proved the f nal scar result signif cantly.

This photograph shows the f rst suture placement in the deep layer where ascial
attachments to the skin are reconstituted. The in ramammary old is a skin-
ascial structure; the breast is held in place by these f bers and not by attach-
ments o the breast itsel to the chest wall.
It is important to secure a good three-layer closure in eriorly. I the in ramam-
mary old has been intentionally lowered, I suture the ascial f bers together in
the desired location. I there is some asymmetry in nipple position, I try to su-
ture the ascia more f rmly on the side with the higher nipple in an attempt to
lower it slightly. I use 3-0 Monocryl or most sutures, but i I want to secure
these ascial f bers or a longer period o time, I use 3-0 PDS.
Antibiotics
Patients are given an intravenous dose o cephalosporins just a ter induction
and be ore the surgical incision. They are also given postoperative antibiotics
or a week. (Most patients only use them or about 5 days). This is probably
not necessary to prevent a surgical site in ection; however, until we know
whether bacteria or a biof lm plays a def nite role in capsular contracture, I will
(perhaps wrongly) continue to give them.
Although I have used a povidone-iodine type o prep or years, a glutaralde-
hyde prep is now recommended by in ectious disease specialists. An advantage
o povidone-iodine is that the prepped area is evident. I currently use a tinted
glutaraldehyde prep solution.
I think that using a nipple shield, an Opsite (Smith & Nephew, London) or
Tegaderm (3M), is a good idea, because the breast ducts carry bacteria. I do
not currently use a nipple shield; I am trying to minimize changes to better as-
sess and compare my own results.
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Chapter 5 • Breast Augmentation
1
5A-6 Incision closure
for subglandular
breast augmentation
5B-6 Incision closure
for subpectoral
breast augmentation

186
Part II • Technique
Drains
Although we are told that blood and, in particular a hematoma, can cause a cap-
sular contracture, I do not use drains. There is very little blood le t in the pocket,
and it is di f cult to remove drains in my patients the day a ter surgery, because
most patients go home the same day as surgery. (Most patients live several hours
away.) In my career, I have had three patients with hematomas a ter breast aug-
mentation that had to be drained. Postoperatively all three patients had so t
breasts without capsular contracture despite the extensive tissue staining and
bruising rom the hematoma.
POSTOPERATIVE CARE
Patients are allowed to use their arms. We provide all patients with a brassiere
in the recovery room. I do not believe that the brassiere does anything or
the f nal surgical result, but some patients eel more com ortable with a sense
o support.
Tape, Bandages, Brassieres, and Showers
We usually place Micropore paper tape (3M, St. Paul, MN) over the incision
and instruct patients to leave it in place or 3 to 4 weeks. They can shower the
next day and pat it dry. It is a good bandage and, since we started using it, ewer
patients call concerned about how the incision is healing.
This patient is shown 3 weeks postoperatively, with paper tape over her in ra-
mammary incisions. Initially the tape does not look as i it will stick, but, once
it warms to body temperature (about 5 to 10 minutes), it is di f cult to dislodge.
I did an experiment on mysel and ound that the Micropore paper tape lasted
longer than generic tape. The adhesive in generic tape tended to coalesce, and
did not adhere as well.
1
5A-7 Wrap-up for
subglandular breast
augmentation
5B-7 Wrap-up for
subpectoralbreast
augmentation

A Mepore type o bandage is placed or the f rst day and is usually replaced a -
ter the shower on the f rst postoperative day. We place a loose type o brassiere
on patients so that they can eel more com ortable with a sense o support. They
are told that they can choose whether to wear a brassiere or not, depending on
their pre erence.
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Chapter 5 • Breast Augmentation
Patients who have their implants in a subpectoral position are also given a strap
to help hold the implant down into the pocket that I created or it. They are
encouraged to wear the strap over the breasts during the f rst couple o weeks i
the implants appear to be riding up. I am not sure it makes any di erence.
I used to ask patients to per orm displacement-type massage exercises when I
used smooth-walled saline implants. I do not think it made any di erence. When
I used both textured and smooth-walled implants I told my patients not to do
any displacement exercises, because it would de eat the purpose o trying to ob-
tain adherence o the textured sur ace to the capsule. Now I only use smooth
implants, and I do not recommend massage.
Vitamin E appears to make some capsules so ten once a contracture develops.
Although I suspect that the e ect is more coincidental than real, I still suggest
to patients that they take 800 IU o vitamin E once daily or about 6 months
a ter surgery. We prohibit vitamin E (along with other medications and herbal
preparations that can cause bleeding) or 2 weeks be ore surgery. Patients can
resume these types o medications 2 days a ter surgery. They are in ormed that
the risk o bleeding is not zero, but it is signif cantly reduced several days post-
operatively.

188
Follow-U p
I try to see each patient at some point during the f rst month or two a ter sur-
gery. I show them how to per orm breast sel -examination by rolling the breast
tissue away rom the implant and eeling the tissue between their thumb and
f ngers.
It is sometimes impossible to get patients to return unless they have problems.
We do call each patient the day a ter surgery and a week later, and we try to or-
ganize a ollow-up appointment. We also ollow-up with a phone call 6 months
a ter surgery and encourage them to return or a visit. No one is charged or a
ollow-up visit. Getting patients to return a year later is even more di f cult. I
go to my o f ce in Calgary once a month, which is where most o my patients
live, so that they do not have to drive this distance. It can still be di f cult to get
them to come in.
PROBLEMS AND COMPLICATIONS
Many o the complications with breast augmentation are the same as those seen
a ter breast reduction, mastopexy, and mastopexy-augmentation. Complica-
tions are implant specif c, pocket specif c, or procedure specif c.
General Complications
Early H ematoma
A ter nearly 25 years in practice, I was particularly ortunate that none o my
primary breast augmentation patients had a single hematoma. My good luck
did not last. I had a patient who developed a hematoma a ter a subpectoral sil-
icone gel augmentation. I have now had three primary augmentation patients
with a postoperative hematoma—one the evening o surgery, one 10 days later,
and one 8 days later. The second patient was using a H ula-hoop, and the third
patient was sitting at her desk.
Part II • Technique

189
Chapter 5 • Breast Augmentation
This woman had a subpectoral breast augmentation using Style 15 304 cc
smooth-walled responsive silicone gel implants placed through an in ramam-
mary incision. The hematoma spontaneously developed 8 days a ter surgery and
required evacuation under general anesthesia.
She did well, and both her breasts remained so t 5 months a ter her surgery.
Analysis
It is important to secure hemostasis by looking or and cauterizing
the known blood vessels be ore closure. This includes the per orator that comes
just above the f th rib medial to the breast meridian. The other arteries that
should be checked are the superf cial branch o the lateral thoracic artery and
the branches medially o the internal mammary artery. It is also important to
assess the undersur ace o the breast (or muscle) or bleeding. H ematomas that
occur several days to weeks later are probably impossible to prevent.

190
Part II • Technique
Late H ematoma
I suspect that most late hematomas result rom some sort o trauma. A mam-
mogram or other injury can act as a closed capsulotomy and tear some blood
vessels that ormed in the capsule.
This woman developed a capsular contracture on the right with this odd type
o distortion 20 years a ter her initial breast augmentation. She said that the
right side was f rm airly early on but it had become more swollen in the past
year. She was convinced that she had saline implants (inserted in 1984). She
had checked with her surgeon during the implant “crisis” at that time and was
assured that they were saline. I have ound this to be a common problem and
have learned not to trust any o the in ormation I receive about previous im-
plants, whether rom patients or health records. Sometimes I have copies o the
implant labels and later f nd that a subsequent procedure was per ormed.
Old, clotted blood was removed rom the pocket. The implant was a Dow Corn-
ing Silastic I silicone gel with an intact envelope. There was a similar implant
on the le t side, but it had ruptured.

The right implant and capsule (top) and the left implant and capsule (calcif ed,
bottom) are shown.
191
Chapter 5 • Breast Augmentation
Cohesive silicone gel CML 230 g implants were placed in the subglandular
pocket. She is shown 4 months after revision.

192
Part II • Technique
This woman presented a ter a several-month history o the right implant in-
creasing in size. She had had Dow Corning implants placed in the subglandu-
lar location in the 1970s. She adamantly denied any trauma or in ection and
had not had a mammogram.
The le t implant had ruptured. The pocket was f lled with a chocolate-like, thick
uid, probably rom a resolving hematoma.

She had the implants removed without replacement. She is shown initially
6 months a ter surgery. One year postoperatively she had the implants replaced
with cohesive silicone gel CMH implants 230 g each. They were placed in the
subglandular pocket. There was a considerable amount o scar tissue on the
right side. She is shown at 18 months a ter the replacement, with a right cap-
sular contracture. The f nal photographs are shown 1 month a ter a right cap-
sular release.
Analysis
Late hematomas are most likely caused by some minor trauma with
some tearing o the implant capsule. The capsule has blood vessels, and these
can be disrupted. Both o the previous patients had resolving hematomas, but
neither remembered any trauma. The implant may or may not be ruptured. The
second patient shows that repeated operations are o ten needed when this prob-
lem occurs. It has been my experience that, when problems occur, it is unlikely
that one corrective procedure will be enough.
193
Chapter 5 • Breast Augmentation
6 months after implant removal

18 months after replacement,
with right capsular contracture
1 month after capsular release

194
Part II • Technique
Infection
I have been ortunate to have had only one true implant in ection in my practice.
I have seen two implant exposures that did not seem to be in ected, but may
well have had some underlying in ectious process that I was unable to identi y.
I have seen an in ection in a tourist who had had implants placed a ew weeks
be ore she traveled. I removed both implants.
This patient’s implant extruded, probably because o thinning o the dermis by
steroids.
This patient developed an in ection a ter a cohesive
gel CML 265 g implant was placed in a subglandular
pocket through a transaxillary incision. She responded
to cephalosporins orally; however, the in ection be-
gan to point, and the implant was removed 6 weeks
a ter the original surgery. She had copious amounts
o clear uid, but cultures were negative (not surpris-
ing because she was on antibiotic therapy).
I believe in giving perioperative antibiotics; I am not sure whether continuing
antibiotics or a ew days or a ull week has any e ect on capsular contracture.
I will continue to use postoperative antibiotics until there is more in ormation
about the role o S. epidermidis and biof lm on capsular contracture.
Other patients have developed redness and pain around the incisions. They were
treated success ully with antibiotics.
Implant Extrusion
Most cases o implant extrusion are related to in ection. This may be compli-
cated by—or caused by—the instillation o steroids into the implant. This pro-
cedure was done in the 1970s and 1980s in an attempt to reduce capsular con-
tracture. Un ortunately, it thinned the dermis and extrusion resulted.

195
Chapter 5 • Breast Augmentation
Implant-Specif c Problems
Edge Visibility
Implants need to be padded with at and/ or breast tissue or camou age. This
presents a potential conundrum when considering breast augmentation in body
builders, who need to have very little body at so that their muscle def nition is
visible through their skin. The implant un ortunately shows equally “well”
through the skin.
The best result rom breast augmentation is achieved with the implant in a sub-
glandular position in a patient who has a good layer o at and breast tissue,
along with good quality skin. Un ortunately, many patients do not have good
padding; these individuals will have a better result with subpectoral placement.
They need to understand that the muscle does not cover the lateral aspect o
the implant, and edge visibility can still be a problem. This is likely to be worse
i there is any capsular contracture.
This patient would have had a better appearance i the implants had been placed
in a subpectoral position, because she had very little breast or at to camou age
the implant edges. These were smooth-walled 240 cc saline implants. Both the
edge and the olds are visible in the upper quadrant. The disadvantages, how-
ever, o subpectoral placement are breast movement (dancing breast syndrome)
and a wider cleavage.

196
Part II • Technique
Rippling
Several actors cause rippling. One occurs with saline implants, when they are
overf lled and have a scalloped edge. Overf lling rounds the implant into a more
spherical shape. The scalloped edges are more visible through the skin.
The saline implant shown on the le t has scalloping o the edges because o over-
f lling. The implant on the right is slightly overf lled, with minimal scalloping.
The second cause o rippling is the traction e ect on the implant that occurs
when it is pulled downward by gravity. The only way to avoid this would be to
have completely spherical implants (which would de eat the purpose).
The implant shown on the le t is a responsive silicone gel implant with a at
back and a rounded ront. The more cohesive, orm-stable implant shown on
the right is less likely to have traction rippling.
Folds
The third cause o rippling is capsular contracture, which compresses the im-
plant and causes visible olding to occur. All o these problems are less likely to
occur in patients with good padding.

Both o these patients had saline implants. The patient on the le t shows the
type o olds that are more common with saline implants (arrow). The patient
on the right shows a old in the implant that shows through the skin (arrow).
These types o olds usually result when there is some capsular contracture that
causes olding o the implant envelope.
Internal racturing o the gel can cause visible olds and rippling with the more
cohesive gel implants. With silicone gel implants that are very cohesive and f rm,
extra care needs to be taken not to orce the implant through a small incision,
because the gel will actually racture internally, while the envelope stays intact.
197
Chapter 5 • Breast Augmentation
The photo on the le t shows a CML implant orced through an opening that
was too small. I did not realize the implant had ractured until I removed it to
per orm more dissection. I did not replace it, but kept it in my o f ce and
watched it as the weeks went by and the shape returned closer to normal. The
same implant is shown on the right, several years later. The racturing o the gel
le t air pockets and visible ractures. Note the typical yellowish discoloration
that occurs in the gel.

198
Part II • Technique
This patient’s breasts were augmented with textured cohesive gel implants. A
f at medial border (arrows) was troubling to the patient, but there was no evi-
dence o capsular contracture.
When the implant was removed, it was evident that it had probably been rac-
tured on insertion, resulting in a f at, indented border (arrows). The implant is
oriented in the photograph as it was in situ.
Double Capsules, Seromas, and Adherence of Capsule to the Implant
True Tissue Ingrowth
Do capsules actually grow into a textured implant sur ace? They do with the
polyurethane coated implants, o ten making the surgeon believe that the
polyurethane covering disappeared when it was in act incorporated into the
capsule (the polyurethane did thin out and some o it was absorbed, but not
completely).
Tissue Adherence
True tissue ingrowth does not occur with textured sur ace implants, but there
is a varied amount o tissue adherence that can occur. The textured sur aces vary

considerably rom one company to another. In my experience, there is no ad-
herence with the Siltex sur ace, but some thick serous uid does develop around
the implant, perhaps because o some shearing orces over the slightly rough
sur ace.
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Chapter 5 • Breast Augmentation
The textured Microcell sur ace on the CML and CMH implants sometimes le t
a pebbly type o indentation in the capsule, as shown above. The Biocell tex-
tured sur ace did promote some adherence. True adherence was more likely to
occur when a tight pocket was created to exactly f t the implant size and shape.
Formation of Rugae
Occasionally, when some adherence did occur, the capsule would contract into
rugae, de orming and olding the implant. It was interesting that these rugae
or olds in the capsule would f ll in with scar tissue.
In this case there was capsular contracture that actually pulled the implant into
an elongated abnormal shape. This is in contrast to the smooth capsule, which
compresses the implant itsel and can push it into an abnormal shape. This pa-
tient had previous silicone gel implants with extensively calcif ed capsules. Both
the capsules and the implants had been removed be ore implant replacement.

Late Seromas and Double Capsule Formation
I have also seen double capsules with the Biocell textured surface in both
the round and shaped implants.
200
Part II • Technique
This woman (5 feet 10 inches tall) had shaped 410MM 460 g implants placed
in a subglandular pocket. She is shown 5 months postoperatively.
Preoperative

5 months postoperatively

She called 17 months postoperatively to say that her right implant was getting
smaller, but I believed that the le t side was getting larger. There was no his-
tory o trauma, in ection, or even teeth cleaning. We decided not to operate,
but to wait and observe.
At 19 months, however, her situation was signif cantly worse.
201
Chapter 5 • Breast Augmentation
17 months postoperatively

19 months postoperatively
When the capsule was opened, the
pocket was f lled with a relatively clear
serosanguinous uid. All cultures (even
or mycobacteria) were negative. A
double capsule is evident in this photo.

202
Part II • Technique
There were two complete capsules on the le t breast. The capsule shown in the
le t photo was adherent to the implant sur ace and had actually compressed the
implant into a rounder shape. (The internal old can be seen through the cap-
sule, as marked by the arrows.) A second complete capsule (shown in the photo
on the right) was attached to the breast tissue. The seroma was in between the
two capsules. The capsules were actually used together just beneath the nip-
ple, preventing the implant rom rotating.
I thought that I was going to be removing the implant and not replacing it, be-
cause I was sure that there was some orm o in ection. Instead, the problem
seemed to be a seroma created by the shear orces o the two capsules rubbing
on each other. I had not obtained a new implant, because o all the bureaucracy
required to do so through the special access system in Canada at the time, and
because I was “sure” that I would not be replacing it.
I decided to remove both capsules and reinsert the same implant.
Capsule attached to the implant surface

Capsule attached to the breast
2 months after capsule removal and reinsertion of original implants
The patient is shown 2 months a ter her revision, with some persistent swelling
but def nite improvement.

She is shown 3 1⁄2 years a ter the revision. There were no urther problems with
the le t breast, but the right breast had capsular contracture (Baker II).
I have now seen double capsules in both the round and shaped Biocell textured
implants. I suspect that there was some orce applied to the le t breast in the
previous patient (who had shaped Style 410 implants), which caused some shear-
ing o the capsule and implant. A second capsule then ormed, causing the
seroma. There was still an attachment anteriorly so that the implant did not
rotate.
When I have removed a round textured implant that has not developed adher-
ence, a type o double capsule starts to orm with a second f lm attached to the
implant itsel .
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Chapter 5 • Breast Augmentation
3 1⁄2 years after revision
A f lmy second capsule is starting to orm around this Biocell textured implant,
which was not adherent but lying ree in the pocket. This f lm can be peeled o
the implant and appears to be very much like a regular capsule. It develops a
very smooth sur ace on the outside (pebbly and adherent next to the implant),
which is quite shiny, made apparent with the camera’s ash.

204
Part II • Technique
This patient had a developmental de ormity and had a right Style 410 FX
360 g implant and a le t CML 230 g implant placed in a subglandular pocket.
The Style 410 implant was removed rom the right breast 6 months postoper-
atively, because the shape was unacceptable. It had been purposely placed with
the base slightly medial to f ll the medial chest concavity, but this maneuver was
unsuccess ul. It was replaced with a CML 470 g implant.
A double capsule was evident on the Style 410 implant. It is shown peeled o
the implant. This was an incidental f nding.
This is the type o seroma that occurs with a Siltex textured implant. I have not
seen a double capsule, however, with this implant.

205
Chapter 5 • Breast Augmentation
Pocket-Specif c Problems
Dancing Breast Syndrome
Muscle movement with subpectoral breast implants is an expected side effect
rather than a true complication. Before patients agree to have the implants
placed below the muscle, they need to be aware that their breasts will move
with muscle contraction. Patients usually do not seem to mind the movement
and often learn to avoid using the muscle; however, they comment that they
can still feel it when they perform certain activities such as opening a jar or walk-
ing with crutches.
This woman had 400 cc saline implants placed in the subpectoral plane. For-
tunately, she did not mind the muscle movement.
This woman had responsive silicone gel implants placed in a subpectoral location.
Both implants were Style 15 304 cc. Note the movement with pectoralis mus-
cle contraction. This is not really a complication, but an expected side effect.

Double Bubble
Surgeons call three di erent problems a “double bubble.” The f rst one is the
water all e ect that occurs when an implant sits high and the breast tissue drops
o the implant, causing a double-prof le appearance with glandular ptosis. The
other two are caused by either contraction o the pectoralis muscle with adher-
ence to the skin or constriction o the f bers between the skin and deeper tissues.
206
Part II • Technique
This patient demonstrates the waterfall effect. This is one orm o double bub-
ble in which the breast tissue acts independently and slides down o the implant.
The usual description o a double bubble is the old that occurs in the lower pole
o the breast. This is caused by two problems. The f rst is the insertion o the
pectoralis muscle f bers through scar tissue to the dermis. The second problem
is lowering o the in ramammary old while the old remains tight.
Pectoralis Muscle Insertion
This woman had subpectoral Style 10 330 cc implants placed elsewhere. She
had also undergone one revision but still had a double bubble on the le t breast,
which was exaggerated with pectoralis muscle contraction.

207
Chapter 5 • Breast Augmentation
At surgery it was clear that the pectoralis muscle edges (shown in the orceps
above) were the cause o the indentation and olding o the skin. This can be
very challenging to correct or two reasons: (1) usually, the old is already slightly
too low and (2) it can be di f cult to prevent readherence o the muscle f bers
into the dermis.
The correction was only per ormed on the le t breast. There is still some asym-
metry with excess lowering o the in ramammary old; however, the double
bubble is not visible at rest (as seen in the photo on the le t) or with muscle
contraction (as seen in the photo on the right).

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Part II • Technique
Constricted Inframammary Fold
This woman had a double bubble caused by her constricted inframammary fold.
She had a tuberous type of deformity, and I did not perform a complete release
on the left breast. Cohesive gel CML 230 g implants were placed in the sub-
glandular pocket through an inframammary incision. She is shown 3 months
after surgery.

This patient appeared to have a double bubble before her surgery. She had
had no previous procedures. Her implants were cohesive gel CMH 280 g each,
placed in a subpectoral pocket through an inframammary incision. Note
that the fold was corrected with the breast augmentation. She is shown 1 year
postoperatively.
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Chapter 5 • Breast Augmentation

210
Part II • Technique
Procedure-Specif c Problems
Tension Bands and Mondor’s Disease
There are two types o bands that can orm in the immediate postoperative pe-
riod: traction bands and those that are caused by Mondor’s disease. The trac-
tion bands are rom a physical pull on the ascia; Mondor’s disease is a throm-
bosis o the superf cial thoracoacromial vein. Both will disappear.
The bands shown above are caused by tension on the ascia; they are not un-
common. They are not sore (as with Mondor’s disease), and they become more
exaggerated when the breast is pulled upward, as shown in these photos. I ex-
plain to patients that the ascia over the chest wall is much like a bed sheet, and,
when it is pulled, banding will orm. These bands settle airly quickly without
any residual e ect, and they do not need to be treated.
Mondor’s disease, conversely, is rare and usually pain ul. True Mondor’s disease
is a thrombosis o the thoracoacromial vein usually just anterior to the axilla (area
between arrows). It is best treated with nonsteroidal antiin ammatories.

Capsular Contracture
Capsules orm around all oreign bodies, but they cause problems around breast
implants, which are supposed to remain so t. As the capsule contracts, it tight-
ens around the implant and causes hardening and distortion. There are two
main capsular contracture classif cations; these are presented in the ollowing
tables. I have used the Baker classif cation to assess my results.
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Chapter 5 • Breast Augmentation
Baker Classif cation
I

The augmented breast eels as so t as an unoperated one.
II, Minimal

The breast is less so t and the implant can be palpated, but it is not visible.
III, Moderate
The breast is more f rm, the implant can be palpated easily, and it (or
distortion rom it) can be seen.
IV, Severe

The breast is hard, tender, pain ul, and cold. Distortion is o ten marked.
Breast Augmentation Classif cation (BAC)
Acceptable
Grade 1

So t, no de ormation
Grade 2

Slightly thickened consistency, none to slight de ormation
U nacceptable
Grade 3

Firm to hard, none to slight de ormation
Grade 4

H ard, severe de ormation
This patient exhibits bilateral capsular contracture with hardening and distor-
tion. She has a Baker III capsular contracture on the right breast and a Baker
IV capsular contracture on her le t breast.

There seem to be two peaks in capsular contracture ormation that I have ob-
served over time in my practice. The f rst peak occurs in the f rst 6 months; this
can be very rustrating to treat and we do not know why it occurs. The second
peak o ten indicates a rupture in the older style o silicone breast implants, which
had previously per ormed well or years and then developed capsular contrac-
ture. This usually indicates that the implant envelope has ruptured and the sil-
icone gel has migrated outside the implant, causing irritation o the implant
capsule. Many patients develop capsular contracture over time or no identif -
able reason. The longer I ollow my patients with saline implants, or example,
the higher the capsular contracture rate.
I have not ound mammograms or even MRIs particularly use ul or diagnos-
ing rupture. Numerous reports o rupture have turned out to be incorrect at
surgery. I usually rely on clinical symptoms when recommending surgical in-
tervention.
Release of Breast Capsules
Capsules can either be released (capsulotomy) or removed (capsulectomy). Cap-
sular release is o ten all that is needed, but I tell patients that this only works in
about hal o the patients; recontracture occurs in the other hal . I the capsule
is very thick or i there is ruptured silicone gel, then I believe that capsulectomy
is indicated.
In a capsular release, access is usually obtained through the initial incision. I
have not attempted a capsular release through an axillary incision, but acility
with the endoscope (which I never achieved) would have made it possible. The
implant needs to be removed in most cases to e ectively release the capsule. In
the past, I ound it easiest to release the capsule with cautery and sometimes
some additional blunt f nger dissection. Today I would not use blunt dissec-
tion; I open the pocket in the desired directions with monopolar cautery or-
ceps and release the capsule where it is tightest, initially per orming a circum-
erential release. The extent o the release depends on where the most distortion
has occurred. The anterior capsule o ten needs to be released so that the im-
plant is no longer compressed.
I the capsular release is not success ul, then a change o pocket or change o
implant type (or both) is attempted. I am not sure that anyone has been able
to demonstrate that one approach is better than another. We can all show good
early results with whatever approach we use or capsular contracture, but it is
not known which approach is best in the long term.
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Part II • Technique

213
Chapter 5 • Breast Augmentation
This patient had capsular contracture in her le t breast, with hardening and dis-
tortion (top photos). She had 300 cc (225 cc
75 cc) saline implants in the
subglandular location. The capsule was released, and the same implants were
placed into a subpectoral pocket. A success ul correction was achieved. She is
shown 1 year a ter surgery.
It is my experience that capsular contracture occurs less requently with the
newer generation o gel implants (see the table on p. 165). The earlier gel im-
plants had a airly high rate o capsular contracture, especially with time; intra-
capsular rupture was requent. My experience with saline implants (during the
time we had to use them or about 10 years because o restricted access) was
that, although they were better than the early-generation gel implants with re-
gard to capsular contracture, they still had too high a capsular contracture rate—
either above or below the muscle.
Removal of Breast Capsules
When the surgeon suspects that the gel implant is ruptured inside the capsule,
it makes sense to try to remove the entire capsule (capsulectomy) and implant
together. Some capsules are so f rm that it is advisable to release as much o the
capsule rom the surrounding tissue as possible and then open the capsule and
remove the implant (some surgeons use suction to empty out the implant),
making it easier to f nally deliver the remainder o the capsule. The process is
much easier with saline implants.

214
Part II • Technique
Inf ltrating the breast (without penetrating the capsule) with tumescent-type
uid (1 L o Ringer’s lactate with 20 ml o 2% lidocaine and 1 ml o 1/ 1000
epinephrine) makes the dissection signif cantly less bloody, but care must be
taken not to penetrate the implant. Less than 200 ml o tumescent inf ltration
is needed per side.
Sometimes the capsules are much easier to remove i the patient agrees to a
mastopexy. The access is easier, but the decision making or the mastopexy it-
sel can be harder i there is any distortion rom the capsular contracture. I it
is known that the implants are saline (and patients o ten do not know), then
the implants can be “de ated” be ore surgery to help determine skin markings
or a mastopexy.
When removing polyurethane implants, it o ten appears as i the polyurethane
has disappeared. These implants are quite cohesive and can be easily removed,
but it is more di f cult to remove the capsule. The polyurethane def nitely thins
out and breaks down; however, because o capsular ingrowth, the polyurethane
has been incorporated into the capsule. The older polyurethane implants had
the polyurethane glued on. The current generation uses newer technology
whereby the polyurethane is used to the implant.
This patient had saline implants in place with capsular contracture. The right
capsule had considerable calcif cation, whereas the le t capsule was relatively
smooth walled, without much calcif cation. The right implant was a smooth-
walled saline 450 cc (375 cc
75 cc) implant, and the le t implant was 425 cc
(375 cc
50 cc).

This patient had previous saline implants (size and type unknown). She pre-
sented with a right breast implant collapse and a le t breast capsular contrac-
ture. Once a collapse occurs, the implant is o ten olded (bottom left). The cap-
sule on the right breast was calcif ed. The top le t photo shows how a capsular
contracture can elevate the breast. Because the capsule is attached to the breast,
it will pull normal breast with it as it contracts. Normally an implant will not
hold up the breast unless some orm o contracture has occurred. Her implants
were removed, and mastopexy was per ormed. She is shown 6 months a ter sur-
gery. The result is asymmetrical. This case shows how di f cult it can be to judge
size and shape when there is capsular contracture around one implant and the
other one is collapsed.
Implant Rupture
Saline Implants
Saline implant leaks are usually caused by a old aw or a f lling valve ailure.
The lea valve that was used previously with saline implants was particularly
prone to ailure. The diaphragm valve appeared to hold out much better, and,
in my experience, most o the leaking occurred rom small holes or small tears
where the implant was olded ( old aws).
215
Chapter 5 • Breast Augmentation

The saline implant on the le t had a lea valve (arrow). To f ll the implant, a tube
was inserted along a tunnel through a slit in the implant beneath the patch. The
(overf lled) saline implant on the right had a diaphragm valve.
216
Part II • Technique
This double-lumen implant has an inner silicone gel with an outer saline-f lled
envelope. The outer envelope was o ten ruptured, leaving the inner envelope
intact.
Saline implants usually only take a ew hours to empty. There is o ten a small
amount o residual saline le t in the implant, but most implants are ully de-
ated within the f rst 24 hours.
We have learned a lot watching what happens to the breast on the side where
a saline rupture has occurred. The breast tends to revert back to its original
shape and position a ter the rupture. The upper breast border becomes lower,
but, interestingly, the in ramammary old also becomes higher. The skin re-
tracts to a certain degree. Observing resolution a ter intentionally rupturing
saline implants helps surgeons determine the best surgical approach.

This patient had her implants intentionally “def ated.” The breast shrank back
a ter rupture. She previously had circumareolar mastopexy-augmentation that
resulted in a f attened, still ptotic breast. With the weight o the implant re-
moved, the in ramammary old rose and the degree o glandular ptosis decreased
without the downward pressure o the implant. The nipple, on average, drops
2 cm with augmentation, as measured rom the suprasternal notch. It tends to
return to a higher position once the implant is “removed.” Both the nipples
and the gland have moved upward with the saline removed. She is shown
21⁄2 years a ter def ation, with the envelopes still in place. I a patient will agree
to have saline removed, it is ar easier to decide on the best approach.
Silicone Gel Implants
217
Chapter 5 • Breast Augmentation
This silicone gel implant on the le t had been ruptured or some time, as evi-
denced by the intense yellow staining. There is gel sticking to and coating the
outside o the implant.
The implant on the right probably ruptured during removal; otherwise, it would
have had more yellow staining. The semi-liquid gel (arrow) could ooze out
around the implant, irritating the capsule. I the capsule itsel were ruptured
(with a closed capsulotomy, a mammogram, or an accident), this gel could leak
out. The body would then wall it o and orm silicone granulomas.

218
Part II • Technique
Scar Contracture
The ollowing patient shows how sometimes the “enemy o good is per ect.”
She requested that her implant pocket be changed back to the subglandular
location to stop the movement with pectoralis muscle contraction. This request
should have been ignored.
This patient presented with bilateral capsular contracture a ter having had sili-
cone gel implants placed previously.
At the time o implant removal the right implant was ruptured and there was
sticky silicone gel coating the sur ace. The implant was stained yellow, indicat-
ing that it had ruptured some time ago. The right silicone gel implant was intact,
but both implants had a thick capsule with some calcif cations. Both implants
were Dow Corning Silastic II 230 cc.

The implants were replaced with 325 cc saline implants (275 cc 50 cc). A site
change was performed from the subglandular to the subpectoral position. The
patient had a good result; however, she was quite unhappy with the movement
with muscle contraction. I did one procedure to release some of the muscle me-
dially, but then I (mistakenly) agreed to put the implants back above the muscle.
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Chapter 5 • Breast Augmentation
New cohesive gel CML 365 g implants were used. Unfortunately, she devel-
oped scar contracture between the dermis and the capsule. A series of fat in-
jections was attempted to improve some of the scar adherence without much
success. The result with the implants under the muscle was good and should
have been left alone.

220
Part II • Technique
Implant Exposure
Implant exposure was more common when surgeons placed steroids in-
side the implant. Exposure now is more likely related to in ection or a
lack o padding.
This breast asymmetry patient had 145 g o in erior breast tissue removed rom
the le t breast. She had 300 cc (300 cc
0 cc) saline implants placed on both
sides in a subglandular position. She is shown 10 months postoperatively with
a le t capsular contracture. Her tissue was too thin laterally a ter a capsular release
was per ormed. She had only dermis between the implant and the skin sur ace.
The dark area in the lower le t photo is the implant visible through the thin
skin. A muscle f ap was brought around to cover the de ect. Later, at injections
were used to improve the contour (not shown).

221
Chapter 5 • Breast Augmentation
Implant Malposition
Bottoming Out
Some bottoming out is to be expected with breast augmentation. Mea-
surements have shown that the nipple will drop, on average, 2 cm from
the suprasternal notch. Pressure of the implant on the inframammary fold
and on the lower pole of the breast causes the fold to drop and ptosis to
develop. The weight of an implant, therefore, causes all three types of
ptosis: some glandular ptosis with dropping of the breast mound, some
nipple ptosis with stretching of the skin in the upper pole, and some
pseudoptosis with dropping of the inframammary fold.
Preoperative

3 weeks postoperatively

5 years postoperatively
Patients are shown this photo to demonstrate that the degree of breast ptosis
increases with time. Larger implants are likely to cause more sagging, especially
in patients with poor quality skin. This is a 5-year follow-up of a patient with
350 cc saline implants placed in a subglandular pocket. The early result at
3 weeks looks good. The inframammary fold has dropped slightly, but the im-
plant has forced the lower pole downward, causing more glandular ptosis. The
nipple has dropped, resulting in nipple ptosis.

222
Part II • Technique
This woman had 320 cc (300 cc
20 cc) saline implants placed in the sub-
glandular location. She is shown 1 week a ter surgery and then only 5 months
a ter surgery. Initially the implants look a bit high; within a short time they have
dropped more than desired. The main e ect o the implant has been to push
the gland, rather than the in ramammary old, downward.
Implant Displacement
Implants can become displaced over time. Many years ago, surgeons added
steroids to the saline implant pocket. This was the likely cause or many o the
displacements that occurred back in the 1970s and 1980s.
The more likely cause now is either poor pocket dissection or the orce o the
implant on the capsule. It is my belie that saline implants are more likely to
cause this type o displacement because o the water-hammer e ect whereby the
saline pounds down on the in ramammary old over time as it moves around in-
side the implant. There is no question that releasing the in ramammary old f bers
is more likely to allow this to happen. I believe, however, that the in ramam-
Preoperative

1 week postoperatively

5 months postoperatively

223
Chapter 5 • Breast Augmentation
Preoperative

5 weeks postoperatively
4 months postoperatively

11 months postoperatively
This patient had a 360 cc (330 cc 30 cc) saline implant on the right breast
and 330 cc (300 cc 30 cc) saline implant on the le t breast placed in the sub-
pectoral position. The right in ramammary old was higher than the le t, and it
was purposely lowered. Un ortunately, over time, the implant pushed the old
down lower and lower. She is seen 5 weeks, 4 months, and 11 months post-
operatively.
mary old o ten needs to be lowered, but the old should be re-created
by suturing the old f bers (they crisscross over a airly wide area) back
down to the chest wall f bers be ore closure. (These old f bers are clearly
shown on the breast reduction video).
Some lowering o the in ramammary old is to be expected as time
and gravity exert their inf uence. Implant displacement is a di er-
ent problem caused by the weight o the implant actually lowering
the in ramammary old.
1
see 6-5 Parenchymal
resection for vertical
breast reduction

224
Part II • Technique
She had a revision per ormed at 11 months, with suturing o the right in ra-
mammary old up into an overly corrected position. Initially the in ramammary
old was overcorrected. It is important to be patient; this can be di f cult when
trying to reassure the patient. She is shown 11⁄2 years a ter the correction. I an-
other revision is contemplated, it would be di f cult to decide whether to lower
the right breast or to try to elevate the le t in ramammary old. Both procedures
are unpredictable.
This type o breast is prone to bottoming out. The patient’s nipples are abnor-
mally high and very close to the upper breast border. Although I recognized
the issue and used only small implants (cohesive gel CMH 230 g implants in
the subglandular location) and tried to keep the pocket high, she still devel-
oped bottoming out, which was progressive.
Preoperative
Initial revision surgery
11 months postoperatively

11⁄ 2 years after revision surgery

225
Chapter 5 • Breast Augmentation
She is shown 1 month a ter surgery. Some argument could be made or plac-
ing the implants under the muscle to take advantage o the occasional tendency
or implants to settle in an abnormally high position a ter subpectoral place-
ment (see bottom o p. 150); however, the patient shown on pp. 223 and 224
still had signif cant bottoming out, even with the implant in the subpectoral
plane. I do not believe that the muscle supports the implant. She is shown again
1 year a ter surgery, with urther bottoming out.
A correction was per ormed with a bilateral capsulorrhaphy. She is shown
6 months a ter surgery—too early or a def nitive assessment o the f nal result.
The nipples remain high.
1 month postoperatively

1 year postoperatively
6 months after capsulorrhaphy

226
Part II • Technique
A neosubpectoral pocket was created or this patient by removing the implant
and dissecting a completely new pocket, still behind the muscle but in ront o
the anterior capsule. She had 300 cc saline implants placed in a subpectoral lo-
cation about 8 years previously by another surgeon. She is shown 5 weeks and
5 months a ter corrective surgery. She did not return or urther ollow-up, be-
cause she was unhappy with the result. This patient requested a signif cantly
larger implant (500 cc Style 120 Biocell textured silicone gel implants), which
tends to counteract some o the potential improvement. The pocket needs to
be underdissected in eriorly to a signif cant degree, or the problem will quickly
recur. It can be di f cult to convince this type o patient that a smaller implant
would more likely provide a better result.
8 years after initial augmentation

5 weeks after correction

5 months after correction

227
Chapter 5 • Breast Augmentation
Conversely, this patient was thrilled with her correction. She originally had sur-
gery elsewhere, with six attempts to f x the problem. She had a Style 410MM
360 g implant on the right breast and a Style 410MF 375 g implant in the le t
breast, placed in the subpectoral location. Note the old created when the pec-
toralis muscle was contracted. Correction was achieved by placing the implants
in a subglandular location, with capsulorrhaphies per ormed on the right breast
medially and all along the in ramammary old on the le t breast. She is shown
33 months a ter the correction. It is interesting that the repositioning o the
implant had the e ect o stretching the upper pole skin and allowing the lower
pole skin to shrink. The suprasternal notch-to-nipple distance on the le t breast
was 18.5 cm be ore surgery and 21 cm a ter surgery (the only incision was in-
ramammary). The nipple-to-in ramammary old distance on the le t was 11 cm
be ore surgery and 9.5 cm a ter surgery.
Before correction

33 months after correction

228
Part II • Technique
This woman had transaxillary subpectoral gel-saline implants placed 25 years
previously. She had replacement surgery elsewhere with 500 cc smooth-walled
silicone gel cohesive I implants placed back into the subpectoral location. Un-
ortunately, the repair to close the tunnel to the axilla did not hold, and the
implant can be seen sliding up toward the axilla. I corrected the problem (cor-
rective surgery was only per ormed on the right breast) by creating a completely
new subpectoral pocket between the anterior lea o the capsule and the mus-
cle. She is shown 2 months postoperatively. I have ound it di f cult to close up
a pocket rom inside the capsule. A good approach is to create a completely
resh, neosubpectoral pocket.
Before correction

2 months after correction