Neo-Subpectoral Technique for Implant Malposition

Scott L. Spear

M. Renee Jespersen

Samir S. Rao

It is generally accepted that revision breast augmentation is more complex and difficult than primary breast augmentation. The most common causes for secondary surgery in previously augmented patients are capsular contracture and implant malposition. In the case in which patients have a failed device or desire a different size, the surgery is straightforward. For the categories of capsular contracture and implant malposition, the implant capsule must be modified or removed, and the surgery becomes more complex. Several methods have been described to remove or modify a problematic implant capsule, and all have strengths and shortcomings (1,2,3,4).

Correcting a poorly positioned implant in a previously formed capsule is difficult. The simplest way to modify implant position is by capsulorrhaphy and/or capsulotomy. By tightening or releasing the existent capsule, the implant within it can be shifted into the new desired position. Efforts to tailor the previous capsule have been effective in the short term, but the malposition may recur once the sutures lose integrity. In addition, repositioning an implant with capsulorrhaphy requires finesse and can frustrate even the most experienced surgeon.

Alternatively, the position of an implant can be changed from subglandular to subpectoral and a new pocket created in that fashion. This offers the benefits of subpectoral positioning, as well as the advantage of a pristine tissue plane in which to work. For the surgeon, this is the near equivalent of a primary augmentation, as the limits of the uppermost portion of the implant pocket can be easily defined in the exact desired position. Should the patient already have a subpectoral implant, however, the change to a subglandular dissection may not be desirable due to local tissue characteristics. This may be the case where tissue is thin and likely to show implant edges or rippling, or in the case of a previous capsular contracture, where placing the implant subglandularly would increase the risk of recurrence (5).

Severe implant malposition in the subpectoral plane can also be addressed by removing the implant for a period of time and allowing the pocket to close. The augmentation is then performed at a later date. It is understandable that most patients dislike this method, and many surgeons choose it only as a last resort.

For capsular contracture the problems are similar. Simple capsulotomy may improve implant position, but it may lead to recurrence. Total capsulectomy is effective at removing the contracture but leaves the surgeon with a large implant pocket, which can lead to difficulty in controlling implant position precisely. This is even more troublesome with the newer generation of form-stable, textured silicone implants, which require a snug implant pocket for adherence and to avoid rotation.

The neo-subpectoral approach in secondary prosthetic breast augmentation combines the advantage of a new pocket dissection without the necessity of a total capsulectomy or a site change to the subglandular position (6). Using this method, the surgeon creates a new implant pocket using the pectoral muscle as the anterior component and the anterior leaflet of the previously existing capsule as the posterior component. Once the new space is dissected, the old capsule is collapsed and secured against the chest wall. This method allows the surgeon precise control over the parameters of the new implant pocket, regardless of the previous implant position. The technique is effective in correcting implant malposition and complex symmastia and may be appropriate in some cases of capsular contracture (Figs. 125.1 to 125.6). Recurrence of previous malposition is rare when the procedure is performed properly, and the surgeon has the ability to precisely control the implant pocket dimensions.

Technique

Preoperative planning begins with evaluating the patient while she is standing or sitting upright. Sometimes the implant malposition is not obvious at rest (as is commonly the case with symmastia) and may be more evident when the patient flexes the pectoralis muscles or leans forward. The desired boundaries of the new breast implant position are then carefully marked. The ideal inframammary fold is marked as well. Proper positioning of the inframammary fold is dependent on the nipple-to-fold distance required for the particular volume and base width of the implant that is to be used. See Figure 125.7.

The choice of which incision to use is largely dependent on the anatomy and findings of the specific case. The “neo-subpectoral” pocket cannot be dissected with current instrumentation through the transaxillary or periumbilical approach. Therefore, if the previous implant was placed by the transaxillary or periumbilical approach, then either the periareolar or inframammary incision may be used for the correction. If the patient had a previous periareolar approach, then it may be desirable to correct the malposition using that same approach unless there is some specific local or technical reason not to. This may be the case if the areolar diameter and parenchymal thickness would not allow for direct visualization of the limits of the pocket, precise dissection, and atraumatic placement of the device. Located at the center of the breast, nearly equidistant from what will be the borders of the new pocket, the periareolar incision allows for clear, equal, and direct visualization of the entire perimeter of the pocket. By virtue of the areola’s location near the “equator” of the implant, it allows visualization from “the high ground” down toward the limits of the pocket. If the patient has an inframammary scar, then the surgeon must evaluate whether or not to use this incision because it may not
provide adequate exposure to dissect the “neo-subpectoral” pocket up and over the implant, especially if the inframammary incision is low and the implant is large. In this case, a periareolar incision may still be preferable. In most cases, the previous incision will suffice.

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