Introduction
Complications continue to be a problem in breast implant surgery with the original prospective meta-analyses (PMAs) studies showing complications and revision rates as high as 30% ( Fig. 12.1 ). When a patient has one major complication or revision, their complication rates continue to increase to over 45% in most studies. I have written extensively about trying to establish standard terminology to classify these complications and deformities, focusing on objective terminology versus subjective terms such as “bottoming out.” In the description of theses deformities, I believe the best terminology is “medial and lateral malposition.” 4–9
Developing strategies to specifically correct these complications in a consistent, reliable fashion is absolutely vital in stopping this cycle of revision. Many of the original described techniques are unreliable. Every plastic surgeon has seen previously placed permanent capsulorrhaphy sutures embedded in the capsule ( Fig. 12.2 ) with the malposition recurring with the same or worsened deformity. Resecting capsule and suturing or strip capsulectomy also has been advocated, and most recently the use of electrocautery or thermocoagulation capsulorrhaphy is gaining increasing popularity. Although I also use this method, it is not easy to quantify or objectify the outcome and there are no long-term data using this technique. ,
We published the original article detailing the vascularity of the capsule and capsular flap tissue in a pig model in 1992, showing the capsular flap alone could support a skin graft. This confirms the clinical correlation that the capsule can support the revascularization of an acellular dermal matrix (ADM) or scaffold; however, I think placing tissue or a scaffold on the underside of an elevated capsule increases the reliability of “take” and revascularization of the matrix. The capsule has been used in breast revision for decades. The first references I found in the literature were by Silver in 1971 and Snyder in 1975, in which use of the posterior capsule was described. I have modified the surgical approach using the posterior capsule as most recently published by Parsa et al., who resurrected this concept of using posterior capsule for synmastia repair. Additional references using the capsule have been sparse, although I have continued to present these techniques in instructional courses and presentations at national and international meetings over the past 20 years and encourage my colleagues to try these techniques at Bioskills Laboratories and every opportunity I have at educational events.
Most surgeons view the posterior capsule flap as an advanced technique, but I have found it fast, reliable, bloodless, reproducible, and easy to teach, with no patients having a complete recurrence in over 500 breasts in the past 20 years. This chapter will detail using the posterior capsule in new ways that most surgeons may have not previously recognized and shows specific techniques and patients that will benefit from these procedures.
Indications and Contraindications
I am continuing to refine a basic algorithm in treating patients with malposition. The general principle is to create a new breast pocket that fits as closely as possible the new breast implant dimensions, centralizing the implant to the new breast pocket. If too much implant is too medial, lateral, high, or low, it will distort and kick the nipple in the opposite direction. Thus, centralization is a critical principle. In addition, when patients come in seeking a revision, they need a solution that will be predictable and will solve their problem. As with patients who present with recurrent capsular contracture, in more than 350 patients I have performed a total capsulectomy and used an acellular dermis as a pectoral extension with a zero percent recurrence rate. Patients desiring revision need solutions. I have been working on an algorithm that is still evolving but currently is as follows:
- •
For patients with less than 1 cm of pocket width, I perform electrocautery thermocoagulation medially, laterally, or both.
- •
For patients with 1–2 cm of extra pocket width, I perform a posterior capsular flap without reinforcement.
- •
For patients with larger breasts or combined breast/implant volume, prior history of significant weight loss or more than 2 cm of pocket width, I perform a posterior capsular flap with reinforcement.
The main contraindication for using the posterior capsule would be if there is no or minimal capsule present or in the case of a very old or calcified capsule. However, these patients usually have capsular contracture and not malposition. In addition, even in patients with very thin capsule medially, particularly below the fourth rib, the capsule with or without the intercostal fascia may be raised as a triangle of tissue and scaffold or ADM may still be used. Once over the fourth rib, even medially the posterior capsule is always sufficient to use, in my experience. In the case of ultra-thin capsules I would recommend a scaffold support as well.
Preoperative Evaluation
Posterior capsular flaps are primarily beneficial in patients with malposition. This includes patients with lateral malposition and medial malposition and is even an option for inferior malposition. Figs. 12.3 and 12.4 present patients with lateral and medial malposition deformities, respectively, who would benefit from this repair technique. Both complications are best visualized and evaluated with the patient in the reclining position.
It is difficult to photograph and document this in the office, but examination with the patient in the reclining view is mandatory. I have often been surprised by the level and degree of deformity when a patient lies down, and the first time you see this should not be in the operating room. Examination of the patient in the supine position is part of my routine evaluation. The worst cases of lateral malposition tend to be in patients with saline implants with a primary transaxillary incision that without endoscopic assistance may lead to overdissection of the lateral pocket. This deformity may be further exacerbated by a laterally sloping chest wall. I have the patients animate, which also may elucidate the degree of displacement. As previously discussed, I will use a posterior capsular flap with any pocket width greater than 1 cm. If greater than 2–3 cm, I will also use an ADM or scaffold to reinforce the repair.
Surgical Techniques
Relevant Surgical Anatomy
In patients with capsular contracture the capsule is a “Foe,” and it should be removed as part of the surgical revision. In patients with malposition, the capsule is a “Friend” and can be used as a significant part of the surgical revision. Capsular tissue is the natural body’s response to a breast implant, and, depending on the implant surface, age or device, implant failure, and individual patient factors, the capsule can be varying degrees of thickness and inherent strength. Just as in a neosubpectoral pocket technique in which the capsular repair can be very strong, it is the same with a posterior capsular flap technique. The majority of the time in patients with significant malposition, the overlying breast and soft tissues are significantly thinned. It is not uncommon for the capsule to be on dermis. It is often difficult or certainly a detriment to perform a neosubpectoral pocket in these patients because it will thin the anterior tissue thickness further. It is exactly these patients in whom it is helpful to elevate and use the posterior capsule. Adding this tissue layer doubles or increases the anterior thickness, rotating the posterior flap and suturing it up and onto the deep surface of the anterior skin flap ( Fig. 12.5 ).
Similar to an anterior neosubpectoral pocket, in which the tissue plane is dissected between the capsule and skin flap/muscle and then collapsed down, the edge of the neo-pocket is incredibly strong. The main issue when elevating the posterior capsule for a medial malposition repair or synmastia, the capsule can be quite thin and adherent to the fifth and sixth ribs medially. Still, I have been able to elevate the posterior capsule 80% of the time. Even if the capsule is adherent to the ribs medially, the capsule and intercostal fascia may be elevated in the rib interspaces as a triangle and the reinforced with scaffolding. Once you have elevated up over the fourth rib or more laterally, the posterior capsule is easily elevated (see following discussion of flap elevation sequence). In cases of lateral malposition the posterior capsule is very easily elevated and is quick and bloodless. You may also choose to elevate some of the pectoralis minor or serratus fascia up with the capsule. It is critical to mark the new dimensions of your new breast pocket medially and laterally and do not overdissect past this line to avoid recreating the prior deformity. Flap elevation and planning will be specifically covered in following sections.
Preoperative Markings, Surgical Exposure With Capsular Flap Elevation, and In-setting
The procedures of preoperative marking, surgical exposure with capsular flap elevation, and in-setting are performed mainly through a 7- to 8-cm inframammary fold (IMF) incision. The implant is removed and the pocket inspected. The new implant width/diameter to be used in the revision as noted, and the soft tissues are manually pressed externally to visualize the approximate location of the new breast pocket. It is important to centralize the new implant to the new pocket. Marks are placed medially and laterally on the posterior pocket, outlining the new pocket dimensions. Marks are made 5–6 cm medial to the new lateral pocket line and 5–6 cm lateral to the medial pocket line toward the center of the breast. These lines are then “hockey-sticked,” or angled, out to the axilla (lateral) and toward the sternal notch (medial). Bovie cautery on cut mode through the capsule and then coagulation mode for the dissection are used to elevate the posterior capsular flap. The dissection is fast, nearly without bleeding, with the flap elevated to the new outer flap dimension line. Be very careful not to overdissect past this new pocket line, because it is very easy to overdissect and recreate the deformity. Often in patients with lateral malposition there is a tight capsule medially and vice versa. If this is present, capsulotomy is performed again to the border desired for the new implant, again keeping the implant centrally located in the new breast pocket. The posterior capsule is then sutured and secured to the anterior capsule with either a 2-0 polydioxane suture (PDS) or a 3-0 PDS, depending on the thickness of the anterior tissue. Vicryl suture may be used if preferred. In the case of a significant deformity of greater than 2 cm, scaffold or ADM support is laid into the pocket and sutured from the border of the cut posterior capsule on the deep/underneath side of the reflected capsule and sutured to the capsule again with PDS. This adds significant thickness to the anterior soft tissue surface and also creates a potential pocket for fat transfer if chosen in the future. The new devices are placed after further hemostasis and antibiotic/antiseptic irrigation. Deep breast fascia is then closed with 2-0 PDS and running 2-0 Vicryl and your standard skin closure. Series of flap design and elevation are shown in Fig. 12.6A–J for medial malposition repair and Fig. 12.7A–E for lateral malposition repair.
