Definitions and Semantics

Stretch deformity resulting in a “bottoming out” appearance of the breast is defined by an increase in distance from a preoperative nipple to IMF (N-IMF) distance to postoperative distance, with the fold remaining in its prior exact position from the time of the primary operation (Fig.  13‑2).

Fold malposition occurs when the implant drops down below the prior IMF location (since the primary operation). This will also result in an increase in the new N-IMF distance; however, the scar rides up on the lower pole of the breast if an inframammary incision was previously used (see section “Inframammary Fold Malposition”).

Surgical techniques for correction of all three of these complications—­bottoming out/stretch, wrinkling/rippling, and capsular contracture—contain many of the same surgical techniques. When approaching patients with these complications, it is important to do as much as we can surgically to improve the result so as to decrease the chance of further recurrence or incomplete correction. Therefore, changing planes to add more coverage over the device, exchanging saline for silicone devices, and using standard techniques are all important. New surgical scaffolds or acellular dermis are often helpful in further supporting the breast soft tissues as an internal bra, hammock, or sling as well as providing a tenting effect over the device to decrease visibility.

The technical differences when correcting or improving these problems will be specifically addressed in each section of this chapter, but because the overall techniques are similar they will be presented together with variances noted.

After defining the exact nature of the deformity, and these key relationships, incision planning is performed to set the final incision in the new IMF. The new implant size and shape may also play a part in the new IMF position. These relationships of implant size range and ideal N-IMF have been determined. A 7-cm incision, or larger if a skin resection is planned, is then confirmed intraoperatively with the skin on maximal stretch. Redundant skin or skin removal to match the N-IMF distance bilaterally should be marked out and included in the initial incision wedge. This is one distinction between a stretch deformity and IMF fold malposition. If a stretch component is present, a wedge of additional skin should be resected to rebalance the breast and ­create a “hand-in-glove” volume to skin match.

Instruments

Five specialized instruments are recommended for this procedure. These include a double-ended breast retractor, an implant spatula, a fiberoptic nonserrated lighted retractor with smoke evacuation capability, a monopolar hand-switching electrocautery, and a good overhead lighting and preferably a fiberoptic headlight (Fig.  13‑3).

Markings and Landmarks

The incision is made ellipsing the prior incision, in the planned location of the prior IMF, or other ideal planned location based upon the new implant to IMF measurement guidelines (Fig.  13‑4).

Incision Length

The length of the incision is somewhat dependent on the style and size of implant. However, for these revision procedures and in particular when using acellular dermis as a support, reinforcement, or as a hammock or sling internally, the procedure can be likened to operating through a “mail slot” (Fig.  13‑5). The greater the visibility, the easier and more efficient may the technique be performed. New funnels, sleeves, or skin protectant sticky drapes should be considered both to decrease implant contamination when passing through the skin, and improved ability to pass an implant through a shorter incision without contamination. This is a requirement for textured devices as the textured surface can more easily imbed skin contaminants and bacteria.

Details of the Procedure

For capsular contracture and wrinkling/rippling procedures, the skin incision is made with a #no.15 blade scalpel and initial dissection is carried through the dermis with electrocautery. Vessels encountered including perforators are prospectively cauterized. Next, for prior sub-muscular implants, with the original implant left in position, dissection is carried down to the superficial breast capsule. Prior placement of tumescent fluid including a dilute 1:1 million epinephrine may also decrease bleeding and help facilitate the capsulectomy. Dissection is then initiated in the cranial direction and to the caudal border of pectoralis major muscle. In the instance of capsular contracture or an older calcified capsule, all of the capsular tissue or capsule below the border of the pectoralis major is resected. In the case of wrinkling and no contracture, it is preferable to keep the capsule intact to provide an additional layer of support and thickness anteriorly. Radial capsulotomy is then performed with preparation of the pocket symmetrically as needed. New implants are then placed, or alternatively a trial implant may be used while an acellular dermis or scaffold is sewn into position with protection of the device with a spatula retractor. The scaffold or acellular dermis is then further inset at the IMF and its sling effect supports the implant, decreasing visible wrinkling. Both experimentally and clinically, the capsule does not appear to form on the deep surface or underneath acellular dermal tissue and thus circumferential capsular contracture is inhibited (Fig.  13‑6 , Fig.  13‑7). Currently our algorithm is to utilize scaffolds for lower pole support and fold reinforcement and acellular dermis for the treatment of capsular contracture.

Lower Pole Stretch Deformity

Preoperative markings are confirmed, with any redundant or asymmetric skin planned out in the resection in the new IMF. The skin incision is made by de-epithelializing the redundant skin in the lower pole. A skin incision is then made at the inferiormost portion of the incision retaining the de-­epithelialized component above. The initial dissection is carried through the dermis with the electrocautery. Vessels encountered including perforators are prospectively cauterized. Next, if an acellular dermis is to be used, with the implant left in position, dissection is carried cephalad to the inferior border of pectoralis major. Capsulotomy is then performed in the region of the fold, estimating the redundant amount of capsule to be resected. ­Preferentially surgical scaffold or acellular dermis is then sutured into ­position along the inferior pectoralis margin, and on top of and anterior to the fresh capsular surface, and finally inset into the region of the IMF. The redundant de-epithelialized dermis may be used to further support the IMF region (Fig.  13‑8).

Pitfalls

It is very common when addressing a complication and performing a breast revision to potentially create a new problem or deformity while trying to correct or enhance another. Take care not to over-dissect the medial and lateral pockets creating a symmastia or lateral malposition. Standard revision techniques for the treatment of wrinkling/rippling, stretch deformities, and capsular contracture have very high recurrence rates, thus reinforcing the soft tissues with a surgical scaffold or acellular dermis or placing these materials as an interposition will provide the best alternative to break the cycle of ­revision and decrease further recurrence or incomplete, suboptimal repairs.

Pearls

Keeping the implant in position as long as possible initially greatly facilitates the capsular dissection and defining pectoralis muscle border. A spatula retractor is particularly helpful during this initial dissection as well. Estimating the redundant skin and capsule that has stretched is sometimes tricky and can be facilitated by knowing the ideal N-IMF relationships with specific volume of implants. The new acellular dermal materials provide a significant adjunct and further reinforce the soft tissues in minimizing further deformity, as well as decreasing recurrent capsular contracture.

Pitfalls

These three complications are among the most difficult to treat in breast ­surgery. Every technique to decrease recurrence and minimize or ­eliminate the deformity should be considered including exchanging saline for gel devices, capsular flaps, or neo-subpectoral pockets, and adding scaffold for breast ­support or acellular dermal tissue. In addition, all materials do not have the same elasticity, so it is important to understand the specific characteristics of the material you are using.

Pearls

Adequate incision size is critical. When resecting additional skin for bottoming out deformities, incision length is not an issue but in other instances, a minimum of 7 cm should be planned. Keeping the original implant in position for the early portion of the dissection greatly ­facilitates the procedure. Ideal N-IMF folds may also be estimated preoperatively based on the final implant size chosen, specifically determining the ­distance on stretch.

Dissection for Capsular Contracture Cases

The skin incision is made with a no. 15 blade scalpel and initial dissection is carried through the dermis with electrocautery. For prior submuscular implants, the original implant is left in position as long as possible with dissection carried down to the superficial breast capsule. Dissection is then initiated in the cranial direction and to the caudal border of pectoralis major muscle. Dissection continues deep to the muscle with all of the capsular tissues or as much as possible resected, as shown in Fig.  13‑9.

In the case of a prior subglandular implant, total capsulectomy with implant removal is recommended and a site change typically performed with or without addition of an acellular dermis as a pectoral extension. Shown in Fig.  13‑10 is a patient on 1-year follow-up with three times recurrent capsular contracture treated with capsulectomy and an acellular dermal matrix as a pectoral extension with completely soft breasts.

Insetting and closure are performed as described earlier in the “Stretch Deformity, Wrinkling, and Rippling” section.

Capsular Flap: Neosubpectoral Pocket

Subglandular Coverage for Wrinkling and Rippling

In cases where a patient will not accept a submuscular implant or where there is no muscle from prior surgery or congenital absence, there are some alternatives. This technique may not produce as significant an improvement as the pectoral extension, reconstructive technique but still may provide improvement. Again minimizing the inherent device wrinkling using an implant with a higher fill volume will provide an advantage. In addition, a surgical scaffold or acellular dermis may be inset either prepectoral or intracapsular, but sutured to the chest wall and placed on some tension to provide for less visible wrinkling through the material versus what the onlay may provide on its own just from the thickness and barrier of the material itself. In these instances, an 8 × 16 cm piece or larger may be oriented vertically and positioned over the device. The medial aspect of the breast typically is the thinnest and thus the material may be placed more medial to maximize coverage, although this may vary patient to patient.