Scope of the problem

More concerning than the general notion that an augmentation does not last a lifetime, is that more than one in five women undergoing a breast augmentation undergoes a second breast surgery within 3 years. That number is unacceptable for a purely elective, cosmetic operation. Worse yet, is that some of these women enter a cycle of revision procedures, in which they endure the expense, risk, and anguish of repeated surgeries in an effort to fix their problems. And some of these problems can never be remedied. There are many women even in their late 20s several years following their augmentation who feel more self-conscious about the appearance of their breasts than they did prior to their initial augmentation.

Most surgeons do not believe that the 3-year reoperation rate is as high as it is, but it has been repeatedly validated by multiple PMA trials by different manufacturers, different implants, and different surgeons. Unless a surgeon had their personal data CRO reviewed in a PMA study, then it would be hubris to suspect their rate to be any lower. There is another hidden lesson that is proved by the similarity in reoperation rates seen in studies of different implants: that the predominant cause for reoperation is not the device, but it is how we educate patients, make surgical choices, and conduct the surgery. This fact is further validated by data from a single surgeon isolated from the remainder of surgeons in the same PMA study, in which that one surgeon had lower reoperation rates than the pooled average of the other doctors in the study. This striking disparity in outcomes with the same device again proves that results are less related to the device than to other factors. As a competitive breast implant manufacturing industry touts the relative advantages of their devices, an unintended consequence is that patients and surgeons alike have come to believe that the device is an important determinant of the result. However, the totality of data suggests that this is false; the largest documented improvements in patient outcomes have come from improved processes rather than any implant.

Surgeons may doubt the extent of this problem due to a natural tendency to remember our happy patients. Moreover, many of our dissatisfied patients have lost confidence in us and have gone elsewhere if they needed a revision. Sometimes, problems are not visible for years after the first surgery, and the patient has moved, the doctor has retired, or the patient has even forgotten the original surgeon’s name. At best, we are only aware of our known personal revision rate, but it is the patient’s revision rate that matters.

How long do implants last?

This is frequently asked by potential breast implant patients but is a very different question from ‘When will I likely need another breast implant surgery?’ Understanding the difference between these two similar but rhetorically different questions offers important insights into the issue of secondary breast augmentation. From a purely statistical point of view, this issue can be rephrased in the following way: ‘If devices fail at a rate of about 1% per year, why is the 3 year reoperation rate nearly seven times that?’

The presumption in asking how long implants last is that device failure will be the likely causative reason for their secondary breast surgery, but in fact it is not likely to be. Most revisions are the result of issues with patient tissue or patient expectations. Weight gain and loss, pregnancy, lactation, gravity, hormonal fluctuations, sun damage and time itself will inevitably make even the non-augmented breast change with time, and with the added weight and pressure of an implant, these senescent changes of the breast can be more rapid and more pronounced. Ptosis, soft tissue atrophy, implant visibility and palpability, skin stretch and capsular contracture are all issues of the patient’s own tissues and not actually of the device. Of course, some devices may be less likely to cause contracture or to be visible with a given degree of tissue thickness, but the role of the device in these issues is almost always less contributory than the patient’s tissues and biology.

Just as the primary augmentation patient presenting today may have sought consultation a year earlier or a year later than they did, so too is there no absolute time frame at which a patient seeks consultation for a secondary surgery. The same problem that would lead one woman to seek an immediate revision may not bother another woman at all or she may not want to undergo surgery. More difficult to define is to understand disparities that occur between the potential offered by a patient’s tissue and the cosmetic goal that she pursues. This process was often set into motion at the time of the first surgery, in which a thorough or honest assessment of her tissue and the limitations it posed may not have been realized or discussed. For instance, patients with such thin tissue that their ribs are visible should not present for secondary surgery wondering why their implants are visible.

A lack of thorough pre-operative assessment and setting of appropriate expectations can lead multiparous women and weight loss patients to not understand why their implants do not stay high and round. Women with subtle forms of pectus carinatum do not understand why they do not have more cleavage. Patients with subtle volume, ptosis, or IMF (inframammary fold) asymmetries may seek revision for issues that are within normal limits. These issues can bring women in for revision surgery before really necessary. Recognizing the limitations of patient’s tissues and informing the patient is an important role for the physician seeing the secondary augmentation patient. These sorts of issues become central in the evaluation of a secondary augmentation patient. The surgeon must assess the interplay of patient tissue and biology with device, surgical technique, and patient expectation.

Know the normal ideal augmented breast

Gillies’s first principle of plastic surgery, ‘know the normal’, is as important with secondary breast augmentation surgery as with any other reconstructive procedure. And the differences between the unoperated ideal normal and the augmented ideal normal should also be understood. Many plastic surgeons fashion themselves as ‘artists’, opposing efforts to characterize surgical aesthetics by any canons of beauty. These concepts never deterred artists such as Da Vinci. And without documenting measurements, we cannot learn from ourselves or from one another. There are only three critical parameters that define the ideal augmented breast: (1) base width and its relationship to N : IMF; (2) amount and distribution of fill within; and (3) implant-soft tissue relationships, including palpability of the implant.

Base width and nipple: inframammary fold distance

There are many different breast measurements that have been described, but none is as powerful as simply looking at the ratio of the base width to the nipple to inframammary fold distance. If these ratios are not optimal, there will be a deformity. Ideally, this relationship should be 11 cm : 7 cm; 12 cm : 8 cm; 13 cm : 9 cm. This holds true in a wide variety of breast types, whether augmented or not. Determining the root cause of variances from these ratios in the secondary patient can be challenging, as it requires defining differences between inframammary fold height on the chest wall, implant height and nipple height. In nearly all cases of a suboptimal appearing breast, there will either be asymmetries in these measurements between the breasts, or an inappropriate relationship relative to the dictates of these canons.

Amount and distribution of breast fill

In the AP view of the ideal non-augmented breast, there is a clear line of demarcation between the breast and the surrounding tissues only from about 4 o’clock to 10 o’clock, when looking at the right breast; the remainder of the breast tapers off gradually without a visible step-off, blending into the surrounding tissues. At the lower portion of the breast, this is what we call the inframammary fold. The only exception to this in the non-operated breast is in the rapidly growing adolescent breast in which the skin has not yet stretched to accommodate the increasing volume, the engorged lactating breast, and in the constricted lower pole breast, which for the same reason, forces the envelope of the upper breast to excessively fill, creating a marked step-off between the implant and the surrounding tissues. In the lateral view, the same breast would be relatively straight or empty in the upper pole, depending upon how full that patient’s breast skin envelope is. It is never convex in the non-augmented breast.

In the augmented breast with ideal implant volume, one that fills the breast but does not stretch the breast, these relationships are still largely preserved. A progressively larger implant will create a more visible delineation of the perimeter of the breast than a non-augmented breast. This may or may not be desirable to a particular patient, but all patients should understand than an implant that creates increasing degrees of this appearance is objectively not natural, and also risks pressure atrophy of the breast parenchyma and progressive stretch of the overlying skin.

Similarly, the ideal upper pole in an augmented breast should also be straight. An upper pole convexity is indicative of over-fill; a concave upper pole indicative of under-fill. Some patients desire that upper ‘bulge’ or ‘shelf’, With nulliparous, young, and tight lower pole skin, there may be situations in which upper convexity is maintained, but with time lower pole skin (unless there is a contracture or mild degrees of inferior pocket closure), will give way to the weight and pressure of the implant, allowing this early upper bulge (whether desired or not) to dissipate as the implant filler redistributes itself towards the bottom of the shell. True ‘drop’ of an implant, as defined by the implant shifting caudally on the chest wall and coming to rest in an inferiorly displaced position, is uncommon and considered a deformity. There are many patients with small and tight breasts who want to achieve a large size and cannot understand why this is unattainable without the upper bulge, and they need to be educated. Similarly, patients with lax envelopes who want only a small increase in volume often do not understand why they still have upper pole convexity, and they similarly need to be educated. Thus the amount of distribution of fill within the breast envelope, consisting of both implant and native tissue, is of paramount importance in determining breast aesthetics.

Implant–soft tissue relationships

Obviously, the non-augmented breast has no implant visibility or palpability, and in the augmented breast, the goal is to make the implant as indetectable as possible. Any woman receiving a breast implant should expect that her implant will in some way and in some positions be detectable. The extent of this is dependent somewhat on the type of the implant, but, moreover, is a function of tissue coverage relative to the size of the implant. A small bag of pebbles would be relatively undetectable if used to augment a ‘small D’ to a ‘mid D’, but no implant on the market today can augment a very small breast to a very large breast and not be obvious. Capsular contracture and implant overfill/underfill all contribute to excessive implant perceptibility. No patient or surgeon should ever expect to eradicate this. The goal is to make this as subtle as possible, and the indication for surgery to correct this is not that the implant is detectable, but whether it is likely to make the implant less detectable in the long run. Nearly as important as the thickness of tissue coverage and the thickness of the capsule, but harder to define, is the dynamic relationship between the implant with the capsule, and the capsule with the overlying tissue. Any study that will enable better prediction of these phenomenon will profoundly help in the avoidance and correction of dissatisfaction following breast augmentation.

Consultation with the secondary augmentation patient

Whether or not you were the original operating surgeon, you must assess the state of the patient’s condition, the limitations posed by their biology or tissue, and the likelihood for improvement. I have seen a tendency for surgeons to be more circumspect about reoperating on their own patients than they would be about operating on a new secondary patient entering their practice. In fact, however, the indications for surgery should be the same. Why would there be this difference? Other than medico-legal issues, clearly there is a tendency when it is your own dissatisfied primary augmentation patient to be more suspicious of changing patient expectations than a shortcoming in the surgical plan or execution. When the patient comes from another surgeon, one can be too quick to be sympathetic to the patient’s requests and to blame the previous surgeon’s poor planning or technique.

Every effort must be made to secure all previous operative records. Incisions, pocket locations, implant type and fills, use of drains, recovery, changes in cup size, lactation and weight loss history, and satisfaction/dissatisfaction with each procedure should be documented. Patients should be asked to give a complete laundry list of complaints or wishes for the revision surgery. One by one, the surgeon must assess the validity of their complaint about each issue, seek the cause or source for the problem, and determine whether or not, and to what extent, each problem might be fixed. It is important to recognize not just requests that are unfulfillable, but also those that are contradictory. For instance, a patient may at the same time ask to be larger, yet have edges that are less visible. A patient may ask to be smaller, yet want to have greater upper fill and not want a mastopexy. Examples of this are numerous, and it is important to consider trade-offs inherent in fixing a particular problem.

The surgeon must always be detailed and conscientious in assessing a patient’s tissues and the limitations they impose on a result, and never is this truer than in the secondary patient. Many of these patients are seeking secondary operations because their expectations were not properly set in the beginning or procedures were done in an effort to attain an unattainable result. With the passage of time and damage to their tissues, they may even be farther from the possibility of achieving their goal than before their first procedure. It is critically important to assess their tissues and their goals, and reconcile the two. This can be a disappointing conversation for many patients, but the sooner they learn the limitations of their tissue, the less suffering they will ultimately endure. In fact, most patients actually appreciate the candor of a physician willing to engage in an honest and direct discussion, even if the content is ultimately disappointing to them.

And for purely selfish reasons, it would behoove the surgeon to discuss limitations of outcome posed by the patient’s own tissues. The dissatisfied secondary augmentation patient is certainly a litigation risk. But short of that, the more realistic the expectations the surgeon sets with the patient, the more likely it will be that the surgeon fulfills the expectation they have given that patient. A common situation with both primary and secondary breast surgery is that there can be a disparity between what the patient wants or is willing to do as opposed to what the surgeon thinks is best. Certainly, the surgeon must never do something they think is inappropriate. But the reality is that sometimes patients just will not do what the surgeon thinks is best. In these situations, it is very important that the patient be informed of the specific trade-offs inherent in their decision, and they must physically sign off on their acceptance of them. Not only does this medico-legally help in transferring responsibility to the patient, the boldness of such a document further encourages patients to accept what their surgeon is encouraging them to do.

While patients in these complex situations may often not select the therapeutic course that their surgeon recommends most highly, a surgeon should never proceed with any course that they feel is not in the patient’s best interest. In fact, to justify doing so by arguing that ‘this is what she wanted’ may be indefensible in court. Plastic surgeons are sometimes pulled in two directions: the demands of the patient and the requirements of her tissues. No other surgical specialty is expected to pay heed to patient requests to the same extent. Ultimately, however, patient demand should not be permitted to press a surgeon toward proceeding with anything they think is inappropriate. Declining to operate on a patient eager to schedule is a key option that the busy reoperative breast surgeon will need to resort to on a frequent basis. It is probably true that the patient will go elsewhere and find a surgeon to meet their request, but that does not make it right.

Secondary breast augmentation surgery runs a spectrum from fairly straightforward surgery to situations that are not only complex, but also even unsolvable. In order to create a treatment plan and to predict the likelihood of improvement, the surgeon must begin by organizing and categorizing each patient’s problems. Only after assessing all of the contributing factors to the deformity can solutions be found.

Not fixing a problem or removing without replacement

No discussion of secondary augmentation is complete without making a serious note of the possibility of suggesting that a patient either accept a problem as it is or undergo removal without replacement. This is far easier said than done, as patients typically have set in their minds a particular appearance they hope to achieve with another revision, or they have enjoyed their augmentation so much that they are loathe to be explanted. Many of the worst problems I have seen have been as a result of a single surgeon repeatedly trying to make things a little better for the patient, only instead to have the patient develop ever-worsening tissue problems. It is nearly impossible to tell our own dissatisfied primary augmentation patients that their situation is not likely to be improved, and that all their money, discomfort, time, and expectations were for naught, and that they should either just accept the current situation or actually pay yet again, but this time to have their implants permanently removed.

It is easier, but also very difficult, to say the same thing to a patient whose previous operations were done elsewhere. A combination of hope that we may help them and wanting to avoid disappointing them has led many a surgeon to offer an operation to a patient whose situation is unlikely to be substantially improved. Unfortunately, if we are to make any serious gains in reducing reoperations, we need to be stricter in defining the circumstances in which we will operate, and the situations in which removing without replacement best serves the interests of the patient.

The only way to achieve success in this regard is if these criteria are discussed and understood by the patient prior to their first surgery. It is nearly impossible to make these issues understood and accepted after the patient has paid for and completed their first surgery with certain expectations in their mind. The situation will not be substantially improved until plastic surgeons as a group all educate their patients. Tebbetts introduced the concept of defining specific ‘out point’ criteria prior to the first operation. His patients must sign off understanding that their surgeon will not perform elective size change unless medical indications or surgeon agreed aesthetic compromises are present, nipple asymmetries <1.5 cm, IMF asymmetries <1.5 cm, and contractures less than a Grade III. The additional benefit of defining these and having the patient sign off on them preoperatively is that it defines a margin of imprecision that the surgeon and patient consider tolerable. Finally, understanding these issues before the first operation further incentivizes surgeons and patients to perform the operation and make the decisions and choices that are most likely to yield an excellent long term result. Similarly, no revision other than explantation without replacement is offered to patients with recurrent capsule contracture after one revision in which all measures were followed that could prevent a recurrence of the contracture, and patients with implant visibility and palpability with tissue pinch <5 mm at the thinnest area.

Causes for reoperation

In PMA studies for both Mentor and Allergan, operation on capsular contracture remains the most common reason for secondary surgery, followed by patient request for size change, scarring, implant malposition, asymmetry, ptosis, and suspected implant rupture. It is interesting to note that actual implant rupture was not listed amongst the top ten reasons for revision of a breast augmentation. It behooves the surgeon to recognize that this list reiterates the importance of patient tissues, surgeon and patient decision making, and surgical technique as a cause of the second operation as opposed to the device itself.

The most complex situation can always be broken down into five causes, each of which has a discrete set of potential solutions: in priority they are parenchyma/ tissue coverage, skin envelope, capsule, pocket position, and the device. As the surgeon assesses each patient, they should carefully consider each of the five key components that may contribute to the problem, even if the complaint does not at first specifically seem to require consideration. Sometimes there is a problem that the patient had not noticed that the surgeon might overlook, only to be noticed after the revision. Most importantly, none of these can be considered in isolation, as issues in each of these categories can cross over and affect the others, and the correction of one problem may reveal an otherwise masked problem in another category or exacerbate what had only been a mild problem in yet another category.

Manufacturers, patients, and even surgeons have excessively focused on the device as a cause of and solution for problems in breast augmentation patients. While there are undeniably substantial benefits in using various implants in specific situations, by and large the causes and solutions of problems are predominantly related to the patient and surgeon decision making, which is often flawed due to inadequate education of the patient at the time of the initial operation. There is obviously interplay between all of these – and that makes the situation more difficult.

Breast augmentation for surgeons and patients initiative (BASPI)

In 2004, a group of plastic surgeons gathered to consider solutions to concerns that were voiced by the FDA during the 2003 panel hearings. There was concern over reoperation rates, amongst others. This group put together algorithms to establish best practice approaches to several clinical situations that are relevant to secondary augmentation. These flow charts did not define a standard of practice, but rather presented a range of options that are available and need to be considered. They demonstrate how a reasoned approach that considers all options, benefits and tradeoffs, one in which the patient participates, can succeed in reducing the cycle of reoperations that some patients experience.

Specifically, there were algorithms for management of concerns of shell disruption or a leaking silicone gel implant, management of stretch deformities and implant malposition, management of size exchange, and management of capsular contracture. Each of the possible alternatives at each point of the decision making process were posed, and the patient had to initial each point in the decision making tree.

Classification of secondary augmentation problems

The following Teitelbaum classification of breast augmentation problems ( Table 8.1 ) not only inventories all of the problems, but it suggests solutions, and the likelihood for improvement. It reminds the surgeon of all possible causes and solutions.

They are listed in their order of priority:

• •
  

  Parenchyma/tissue coverage

  
  
• •
  

  Skin envelope

  
  
• •
  

  Capsule

  
  
• •
  

  Pocket position

  
  
• •
  

  Device.

A patient is given two scores: one for their appearance at the time of consultation, and another for the patient’s expected result following surgery. Like the Glasgow coma scale, the lowest score indicates the greatest deformity and the highest score indicates the ideal normal. The highest score of 15 would come from the maximum score of 3 for each of the 5 categories. The lowest score of 5 would come from a score of 1 for each of the categories. Each of the five categories is given a score between 1 and 3 according to the following scale:

• 1.
  

  Significant deformity

  
  
• 2.
  

  Minor deformity

  
  
• 3.
  

  No deformity.

A patient is first scored according to the appearance at the time of presentation. All of the information derived from the history and physical examination are culled and analyzed within the structure of these 5 categories, in order to give a preoperative score. After scoring each of these five categories in the patient’s current condition, a second scoring is predicted for the various surgical plans being considered. This helps patients to select which option best meets their needs, and even whether the costs and risks of surgery are enough to justify surgery. This system forces surgeons to look at each of the relevant categories of the surgery and make an assessment of the likelihood of improvement for each. Without such systematic thinking, it is all too easy to inadvertently neglect a pertinent issue or trade-off.

This system also helps to reconcile trade-offs and secondary deformities, e.g. the submuscular patient with adequate soft tissue coverage who elects to go submammary who preoperatively has a ‘3’ for the soft tissue score, may go down to a ‘2’ for that in an effort to raise a ‘2’ for minor ptosis to a ‘3’. The complexity of these situations requires an organized and coherent approach with which to attempt to quantify the advantages and disadvantages of the various options.

Parenchyma/soft tissue coverage

Assuring optimal soft tissue coverage for a patients lifetime is the highest priority in secondary breast augmentation, just as it is in primary breast augmentation, and the lack of it is the most prognostic sign of an unsatisfactory outcome. If there is enough tissue coverage, subtle implant malposition can go unnoticed, severe implant folding can be undetectable, stretched and thin skin can still be kept full, and even capsular contraction can be hard to feel. We can change implants; we can move implants; we can reduce skin with mastopexies; we are often successful at treating capsular contracture. But unless the implant is submammary and we can switch to submuscular or dual plane, we do not yet have a way to consistently and significantly augment the soft tissue of the breast. So if a patient has a problem related to very thin tissue coverage, no implant or perfectly executed surgery can fix all of the patient’s problems.

If a patient has abundant soft tissue, there rarely is a problem that cannot be substantially improved. On the contrary, there is a rarely a patient with very thin and inadequate tissue for whom a perfect result can be achieved. This truth can be extremely difficult for patients to accept – particularly in a culture in which excessive thinness is so celebrated – and actually can be difficult for surgeons themselves to recognize and accept as well. Obviously, many augmentation patients initially presented because of having small breasts with thin parenchyma. Large implants can further put pressure on the parenchyma, causing increasing soft tissue thinning from pressure atrophy. Tissue can further atrophy following lactation subsequent to the original augmentation. Some patients have had parenchyma removed along with capsular tissue when undergoing previous capsulectomies. In the era of mass silicone fear in the 1990s, many other women unfortunately underwent significant resection of otherwise normal parenchyma and even muscle.

In fact, some secondary breast augmentation patients have soft tissue that is so thin that they are best thought of as if they were subcutaneous mastectomy patients. Some of these patients still bring in photos from the Internet of women with substantial parenchyma thickness as examples of how they want to look. It is very difficult, but important to inform them that their expectations should be based more on the appearance of a subcutaneous mastectomy reconstructive patient than the elective cosmetic patients whose appearance they wish to emulate. There is a paucity of photographs of thin-tissued secondary augmentation patients available, so it should come as little surprise that few if any of these patients are at all aware of how difficult a situation they are in. In fact, subcutaneous mastectomy patients can even be in a better situation than some secondary augmentation patients, as repeated augmentation surgeries and pocket changes can result in a pectoralis that has been partially resected, avulsed off of the sternum, or in some other way allowed to window shade so far cephalad such that it is no longer can cover the implant as well as an undamaged pectoralis can cover the implant in a subcutaneous mastectomy situation.

Patients and surgeons must be reminded that breast implants are at their best when they serve as a platform for the existing breast tissue, projecting it forward, thereby allowing the existing parenchyma to be seen and felt. But when coverage is thin and the implant is large, the implant is not augmenting the existing breast so much as it becomes the breast. To date, there is no device that can mimic the natural soft tissue of the breast. An implant should be viewed not as a soft tissue replacement. Tissue coverage and implant size go hand in hand: coverage inadequate for a large implant may be adequate for a smaller implant. But for this section, we will consider the thickness of the coverage; finding an implant of the appropriate size will be addressed in the device section.

Assessing tissue coverage and the parenchyma

Tissue coverage should be assessed in all breast augmentation patients, both in primaries and secondaries, even if the patient’s complaint at that moment does not specifically relate to coverage issues. Tissue coverage always becomes the most important issue affecting the appearance and long term result in a breast augmentation, and it should be assessed before planning any surgery. Caliper pinch thickness at the superior, inferior, medial, and lateral poles should be documented, as well as the visibility of the implant edge. The position of the implant relative to the muscle must be assessed. The patient should contract her pectoralis by pushing her hands together in front of her chest while the surgeon observes the motion of the chest and palpates the attachment of the pectoralis to both the sternum and the ribs along the medial inframammary fold. Usually, one can determine whether the implant is in front of or behind the pectoralis muscle.

In some situations in which the implant is purportedly retromuscular, this exam can reveal that there is actually little or no coverage. This can be seen in cases of severe ptosis, in which case the implant sits so far caudally, that even its superior border sits beneath the inferior border of the pectoralis. It is also seen when the pectoralis was dissected off of the sternum, allowing it to window shade superiorly, slipping over and above the implant. This is possible with every incision, but it is most commonly observed with the periareolar incision, often in cases of very small areolas. This may be due to poor visualization, or a loss of landmarks in which the surgeon, while dividing pectoralis muscle origins along the medial inframammary fold, continues up too far along the sternum until level with the point of access at the areola, exacerbated by the destruction of fibrous attachments between the superficial surface of the pectoralis and the deep surface of the gland, some extent of which is nearly unavoidable with the peri-areolar approach. Interestingly, this is the opposite of the pattern typically seen with a blunt transaxillary approach, in which the muscle is frequently not adequately taken down along the IMF, leaving an implant positioned too high.

While coverage is the main consideration with parenchyma, other significant issues exist. Some patients with lower pole constriction may have a deformity from inadequate release and may still require release. This can be seen in the tuberous or constricted breast. Conversion of a subpectoral to a dual plane type II release can allow access to the deep surface of the gland for scoring to allow expansion. Animation deformities can exist with dual plane, total retromuscular, or partial retropectoral coverage. Total muscular coverage is virtually impossible without wide exposure and lifting the serratus off of the chest wall, which can be bloody, painful, and prolong recovery. Animation deformities decrease significantly with dual plane compared to traditional partial retropectoral pockets.

Management of coverage/parenchyma issues

The only reliable method of increasing soft tissue coverage is to convert from a retromammary to a retromuscular pocket. If the implant is already truly retromuscular, there is often little to do to add substantial tissue coverage.

Skin envelope

Assessment of the skin envelope

In the primary augmentation patient, measurement of skin stretch by pulling forward on the medial border of the areola to see the maximum amount the skin can be distracted has been described and is de rigueur for many surgeons. This can also be done in an identical manner on the augmented patient and documented. Absent quantified, documentable numbers, information cannot be recorded for the benefit of the patient, and surgeons cannot discuss amongst themselves in order to further medical knowledge.

It is important to assess the quality of the skin and its potential to stretch. It is unfortunate that we do not yet have an accurate way to either quantify or predict that potential. But even rough assessments are important. For instance, it is important to point out striae and obviously thin tissues to patients, so that they specifically understand that these are issues inherent to their tissue that the surgeon cannot improve. One of the most important parameters to be measured and documented is nipple to inframammary fold distance. The rule of 7 cm, 8 cm, and 9 cm has been published and is a reliable indicator of the ideal distance for implants of 200, 300, and 400 mL respectively. A special note must be made about patient request for upper pole fullness. A common request of the secondary augmentation patient is to have more upper pole fullness. Unless the patient’s lack of upper pole fullness is due to placement of an implant that is small relative to the patient’s breast tissue – which is uncommon – the problem is likely due to a stretched lower pole.

The breast fills from the bottom up, just like a bucket being filled with water. The greater the lower pole laxity, the greater the volume it will take to fill the upper breast. But the surgeon should rarely expect to gain long lasting upper pole fill by filling the lax breast with an ever-larger implant. This poor decision is frequently made. While this can gain short-term improvement in upper pole fill, if the lower pole is stretched, it frequently restretches even worse than it was before, resulting in a one-step forward and two-step backward situation.

Sternal notch to nipple is also a helpful measure of asymmetries, but is not an absolute indication of whether a nipple needs to be moved superiorly. In the augmentation patient, the issue is the position of the nipple–areola complex relative to the breast mound and its axis relative to the horizon. If a nipple–areola complex is low on the breast mound or pointing down, one must determine first whether the breast mound is in the right place, or if the mound is high. A high riding implant can simulate ptosis; similarly an implant that is positioned too low can give the nipple–areola the appearance of being too high. Capsular contracture can also pull an implant superiorly, giving the illusion of a low nipple–areola complex, and treating the contracture at times can create a proper relationship of the nipple to the breast mound. A partial retropectoral pocket that holds an implant too superiorly can similarly make the nipple look low on the mound, as can too large an implant for the N:IMF distance. One must be alert to all of these possibilities when assessing the skin envelope of an augmented breast.

Capsular contracture

While capsular contracture remains the most common reason for revision surgery in published data, the use of antibiotic irrigation solution and relatively bloodless surgical technique have made this an increasingly uncommon phenomenon. Patients and surgeons must understand that Grade II ‘contractures’ are non-pathologic, and do not require revision. Only III or IV contractures that are distorted or painful require or warrant surgery. There should be no expectation that a II can ever be converted to a I over the long term, and patients without distortion or pain should not have surgery only for reasons of the capsule.

Treatment

The workhorse treatment for capsular contracture is the complete capsulectomy. Since a substantial body of evidence suggests an infectious etiology to contracture, a capsulotomy, which leaves capsule behind, should not be viewed as a definitive treatment for capsular contracture. Capsulotomy should not be viewed as a definitive treatment for capsular contracture; it is best reserved for opening up areas of either closed off or underdissected pocket that are preventing an implant from occupying its intended position.

Capsulectomy for capsular contracture should be done as bloodlessly as possible, and the new implant should not be placed until fastidious electrocautery hemostasis and antibiotic irrigation has been completed. The superolateral portion of the capsulectomy almost always tends to be the most difficult to dissect with excellent hemostasis, owing probably to a combination of reduced visibility in that area and an abundance of muscle perforators. One must avoid the temptation to use excessive distracting forces on the capsule at this point which can result in tearing of blood vessels which stain tissues with blood, leading to a difficulty in visualizing the vessels, as well as increased post-operative pain and potentially inflammation that can lead to a recurrence of the capsular contracture.

The pocket should be thoroughly washed of all debris with antibiotic solution, and the antibiotic solution should be allowed to sit within the breast in an attempt to sterilize it. If there is any fluid observed around the implant, it should be sent for culture for aerobes, anaerobes, acid fast and fungi, with instructions to hold the culture for at least 3 weeks and consider plating on enriched media if there are PMNs on the Gram stain or the surgeon has a suspicion that there may have been a contamination, perhaps owing to a slightly inflamed capsule, or the quantity or color of fluid. If cloudy fluid is found, the surgeon should consider not placing any implant. All implants carry labeling that restricts them to single-use. An implant that develops a capsular contracture should therefore not be reused, even in the same patient. Furthermore, since bacterial contamination is a possible etiology, it would be illogical to use the same prosthesis again. And the shell may have been weakened from the contracture or trauma at the time of the initial surgery, and it makes sense to use the opportunity of having a patient asleep with the capsule opened to start afresh with a new device. This has always sounded inherently logical to me, but I continue to see patients who had their implants removed and the same ones replaced in the setting of capsular contracture.

The role of devices

New devices may themselves offer some improvement in reduction of capsular contracture. Saline and low-bleed silicone with barrier shell technology seem to have roughly similar contracture rates, below those of earlier-generation silicone gel technology. The lowest rates have been shown with the highly cohesive form stable implants, but no direct comparison in similar groups has been done between them and responsive silicone. Surface texturing may offer some advantage over smooth-surfaced implants, perhaps most significantly if the implant is placed in the submammary position. So long as the issue of texturing remains unresolved, the option of placing a textured implant should probably be at least discussed with any patient having an operation for capsular contracture.

Pocket position

It is of course impossible to know exactly the position of a pocket by observing a patient externally. This division puts into one category all causes of implant mal-position. Since an implant sits wherever the pocket is, implant malpositions can best be thought of as pocket malpositions. Implants can be malpositioned inferiorly, superiorly, medially, or laterally.

Device

This is listed as the final cause of revisions as PMA studies consistently demonstrate similar rates of revision surgery across various implant types. If clinical trials of quite different devices yield similar revision rates, then the causes of the revisions have more to do with surgeons’ processes and patients expectations than it does with the devices themselves. Just by the statistics, soft tissue coverage, skin stretch, implant malposition, and capsular contracture are far more common causes of secondary breast surgery, and addressing them at the time of revision surgery is far more important than device changes. It is important for surgeons, patients, and manufacturers to distinguish problems that are caused and solved by the device as opposed to other factors.

But since we are talking about revision of breast implant surgery, there is understandably significant focus on the breast implant itself. While frequently there are issues related to the breast implant, and sometimes the breast implant itself can be the driving force for the operation, the surgeon should think about optimizing all of the other factors in every revision case. No device change should ever be relied upon to fix an unsolved problem in any of these other arenas.

Results

Case 1

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