Case 36 Secondary Breast Deformities (Reconstructive and Aesthetic)
36.1 Description
Breast mounds are large and out of proportion to her body habitus
Irregular contour of the breasts in repose
Breast asymmetry with the right breast larger than the left
Nipple-areola complexes (NACs) are not in the center of the breast mounds
Dynamic animation deformity of breasts with activation of pectoralis muscle
36.2 Work-Up
36.2.1 History
Age, medical comorbidities, anticoagulant use, and smoking history
Pregnancy and breastfeeding history, and plans for future childbearing
History of breast disease (e.g., fibro-adenomatosis, nipple discharge, mastodynia)
Surgical history of all breast procedures performed and postoperative courses
Prior pertinent imaging studies (mammography, ultrasound, computed tomography [CT], magnetic resonance imaging [MRI])
Family history of breast cancer
Current bra size and desired breast size
Motivation for surgery (i.e., chief complaints)
Itemize patient’s chief complaints (list each deformity described during your consultation)
Establish timeline when deformity is first noted and whether stable or still progressing
36.2.2 Physical Examination
Perform static and dynamic examination: Breast animation deformity (BAD)
Examine with the patient in standing, sitting, and supine positions
Perform qualitative exam (Fig 36.1) and establish quantitative measurements (Table 36.1, Table 36.2).
Evaluate breast shape, skin quality, and adequacy of tissue envelope
Identify any asymmetries of the breast (volume, NAC, inframammary fold [IMF] position), thoracic wall, etc.
Palpate for breast masses or axillary lymphadenopathy
Identify skin dimpling or nipple discharge
Any findings must be evaluated before surgery
36.2.3 Pertinent Imaging or Diagnostic Studies
Order diagnostic studies (ultrasound, CT, MRI) as indicated if needed to establish operative plan
Rule out implant rupture, evaluate for fat necrosis, and assess chest wall abnormality
American Cancer Society guidelines for clinical breast exam (CBE) and mammography should be followed (see Chapter 35)
36.3 Patient Counseling
Discuss risks and benefits of available operative techniques to address patient’s concerns
Establish an accurate understanding of the patient’s goals from the surgeon’s perspective and realistic expectations of the final result from the patient’s perspective
If the patient’s expectations are unrealistic, do not be afraid to communicate this
If necessary, recommend getting a second opinion
Discuss other treatment options/alternatives, if available
Thorough discussion of existing asymmetries and potential complications
If implants are involved: Rupture screening recommendations, rates of revisional surgery (approximately 20%), responsibility for cost of revisions if the procedure will not be covered by insurance, and eventual need for implant exchange or removal
Inform the risks and common presentations of Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)
BIA-ALCL is a predominantly textured implant–associated disease, although it is premature to conclude at this point that it cannot occur in smooth implants
Both silicone (57%) and saline (43%) implants have been linked to BIA-ALCL with no specific predilection
Discuss potential need for subsequent additional surgeries (e.g., repeat fat grafting, at the earliest 3 months later)
Estimated time needed for recovery and postoperative activity restrictions
36.4 Treatment
Establish and document a detailed operative treatment plan (see tables 36.1, 36.2, 36.3)
Match each deformity with the intended technique to address it
Sequence of operative steps to save time and prevent mistakes
For example: Harvest fat first so that processing can be done on the back table while actual surgery can proceed; unpack implant/acellular dermal matrix (ADM) right before using it, etc.
Preoperative markings with the patient in an upright sitting position:
Standard reference lines (i.e., breast meridian, jugular fossa nipple, IMF)
Foot print of breast mound/implant pocket (present and desired)
IMF positions (present and desired)
Position of the NAC (present and desired)
Areas that require volume enhancement (fat grafting) versus volume reduction (lipo)
Areas identified as adhesion zones that require adhesiolysis and/or onlay grafting
Display written operative plan (sequence of steps involved) for all to review (Fig. 36.1)
Printout or write on white board
Display preoperative photos illustrating the deformities to be addressed
Assess the capsule: Re-operative surgery most often involves capsulotomy, capsulectomy, or capsulorrhaphy
Volume reduction or enhancement: Also includes the contralateral breast for symmetry
NAC positioning: Mastopexy (peri-areola only or pedicled)
Animation deformity: Change of pocket positioning versus selective denervation of the lateral pectoral muscle involved
Table 36.1 Breast examination—descriptive findings
Right
Left
Asymmetry in shape
Yes/No
Yes/No
Asymmetry in volume/size
Excess/Deficit
Excess/Deficit
Soft tissue deficit
Yes/No
Yes/No
Foot print violation
Yes/No
Yes/No
Bottoming out
Yes/No
Yes/No
Upper pole over-projection
Yes/No
Yes/No
Symmastia
Yes/No
Yes/No
Base width
Too large/Small
Too large/Small
Vertical breast height
Too high/Low
Too high/Low
Animation deformity
Yes/No
Yes/No
IMF
Too high/Low
Too high/Low
Capsular contracture (Grade 1–3)
Double Bubble (Type A/B)
Yes/No/A/
Yes/No/A/
Costo-cartilaginous junction
Prominent/Normal
Prominent/Normal
Anterior chest wall
Prominent/Normal
Prominent/Normal
Abbreviation: IMF, inframammary fold.
Table 36.3 Treatment plan
Intended operative steps
Right
Left
Capsulotomy/Capsulectomy
Yes/No
Capsulorrhaphy
Yes/No
Volume reduction/Enhancement
Yes/No
Breast tissue reduction
Yes/No
Implant exchange
Yes/No
Yes/No
Skin envelope reduction
Yes/No
NAC position (Mastopexy)
Yes/No
Soft tissue support needed
Yes/No
ADM/mesh needed
Yes/No
Fat grafting
Yes/No
Animation deformity
Yes/No
Implant pocket change
(retro vs. pre-pectoral)
Yes/No
Selective denervation
(lateral pectoral muscle)
Yes/No
Abbreviations: ADM, acellular dermal matrix; NAC, nipple-areola complex.
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