Revision Breast Augmentation - dr teitelbaum · Chapter 9 • Revision Breast Augmentation 77 5. Pearls: Adequate incision size is critical. When re-secting additional skin for bottoming

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Chapter 9. Revision Breast AugmentationBradley P. Bengtson, MD, FACS; Steven Teitelbaum, MD

Stretch Deformity/Wrinkling RipplingThere are a number of consistent complications in sec-ondary breast surgery that remain the primary drivers forrevision. These include Capsular Contracture, Malposi-tion, Wrinkling and Rippling and Stretch Deformity ofthe lower pole. Many of the methods of repair are similarand will be shown, clarified, and presented.

INCISION PLANNING

1. The incision planning for revisional breast surgery forthese conditions depends on a variety of factors suchas prior incision placement, and whether there areadditional complications or deformities present, but ingeneral an inframammary approach is preferred. Withan accompanying stretch deformity present it is usually beneficial to resect redundant lower pole skinto help restore symmetry to the contralateral side andthe optimal nipple to fold proportions, and to haveequal distances from the nipple to inframammary fold(IMF) bilaterally. A minimum of a 7-cm-long incisionis typical to facilitate exposure and perform the pro-cedure well, particularly if an acellular dermal matrixis used (Fig. 9-1).

Definitions and Semantics

Stretch deformity resulting in a “bottoming out” appear-ance of the breast is defined by an increase in distancefrom a preoperative nipple to IMF (N-IMF) distance topostoperative distance, with the fold remaining in itsprior exact position from the time of the primary opera-tion (Fig. 9-2).

Fold malposition occurs when the implant dropsdown below the prior IMF location (since the primaryoperation). This will also result in an increase in the newN-IMF distance; however, the scar rides up on the lower

pole of the breast if an inframammary incision was previ-ously used. (see Fold Malposition.)

Surgical techniques for correction of all three of these complications: Bottoming out/stretch, wrinkling/rippling,and capsular contracture are essentially the same. Whenapproaching patients with these complications, it is impor-tant to do as much as we can surgically to improve the resultso as to decrease the chance of further recurrence or incom-plete correction. Therefore, changing planes to add morecoverage over the device, exchanging saline for siliconedevices, and using standard techniques are all important.Acellular dermis is often helpful in further supporting thesoft tissues as an internal hammock or sling as well as pro-viding a tenting effect over the device to decrease visibility.

The technical differences when correcting or improv-ing these problems will be specifically addressed in eachsection of this chapter, but because the overall techniquesare nearly identical they will be presented together withvariances noted.

Minimum 7-cmincision

Old scar-stretchdeformity

New IMF

Figure 9-1

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Chapter 9 • Revision Breast Augmentation 73

2. After defining the exact nature of the deformity, andthese key relationships, incision planning is performedto set the final incision in the new IMF. The new implantsize and shape may also play a part in the new IMFposition. These relationships of implant size range andideal N-IMF have been determined. A 7-cm incision, orlarger if a skin resection is planned, is then confirmedintraoperatively with the skin on maximal stretch.

INITIAL DISSECTION

1. Instruments: Five specialized instruments are recom-mended for this procedure. These include a double-ended breast retractor, an implant spatula, a fiberopticnonserrated lighted retractor with smoke evacuationcapability, a monopolar hand-switching electro-cautery, and a good overhead lighting or fiberopticheadlight (Fig. 9-3).

2. Markings/landmarks: The incision is made ellipsing theprior incision, in the planned location of the prior IMF,or other ideal planned location based upon the newimplant to IMF measurement guidelines (Fig. 9-4A,B).

3. The length of the incision is somewhat dependent on the style and size of implant. However, for theserevision procedures and in particular when usingacellular dermis as a support, reinforcement, or as a hammock or sling internally, the procedure can be likened to operating through a “mail slot”

(Fig. 9-5A,B). The greater the visibility, the easier andmore efficient may the technique be performed.

4. Details of procedure: Capsular contracture and wrinkling/rippling procedures

The skin incision is made with a #15 blade scalpeland initial dissection is carried through the dermis withelectrocautery. Vessels encountered including perfora-tors are prospectively cauterized. Next, for prior sub-muscular implants, with the original implant left inposition, dissection is carried down to the superficialbreast capsule. Dissection is then initiated in the cranialdirection and to the caudal border of pectoralis majormuscle. In the instance of capsular contracture or anolder calcified capsule, all of the capsular tissue or cap-sule below the border of the pectoralis major isresected. In the case of wrinkling and no contracture,it is preferable to keep the capsule intact to provide anadditional layer of support and thickness anteriorly.Radial capsulotomy is then performed with prepara-tion of the pocket symmetrically as needed. Newimplants are then placed, or alternatively a trialimplant may be used while an acellular dermis is sewninto position with protection of the device with a spat-ula retractor. The acellular dermis is then further insetat the IMF and its sling effect supports the implant,decreasing visible wrinkling. Both experimentally andclinically, the capsule does not appear to form on thedeep surface or underneath acellular dermal tissue and

A B C DFigure 9-2. A. Normal implant position. B. Fold malposition. C. Lower pole stretch deformity. D. Wrinklingand rippling.


74 Chapter 9 • Revision Breast Augmentation

Figure 9-3

Incision site

A B

Figure 9-4

thus circumferential capsular contracture is inhibited(Figs. 9-6A–D; and 9-7A,B).

Lower Pole Stretch Deformity

Preoperative markings are confirmed, with redundantskin planned out in the resection in the new IMF. The skinincision is made by deepithelializing the redundant skin in the lower pole. A skin incision is then made at theinferior most portion of the incision retaining the deep-ithelialized component above. The initial dissection iscarried through the dermis with the electrocautery. Ves-sels encountered including perforators are prospectively

cauterized. Next, if an acellular dermis is to be used, withthe implant left in position, dissection is carried cephaladto the inferior border of pectoralis major. Capsulotomyis then performed in the region of the fold, estimating theredundant amount of capsule to be resected. The acellu-lar dermis is then sutured into position along the inferiorpectoralis margin, and on top of and anterior to the freshcapsular surface, and finally inset into the region of theIMF. The redundant deepithelialized dermis may be used tofurther support the IMF region.

5. Pitfalls: It is very common when addressing a compli-cation and revising to create a new problem or deformity



A BFigure 9-5

A B

C DFigure 9-6



while trying to correct or enhance another. Take carenot to overdissect the medial and lateral pockets or tocreate a symmastia or lateral malposition. Standardrevision techniques—particularly for wrinkling/rippling, stretch deformities, and capsular contrac-ture—have a very high recurrence rates, thus reinforc-ing the soft tissues with acellular dermis or placing thismaterial as an interposition will provide the best alter-native to decrease further recurrence or incomplete,suboptimal repairs.

6. Pearls: Keeping the implant in position as long as pos-sible initially greatly facilitates the capsular dissectionand defining pectoralis muscle border. A spatula retrac-tor is particularly helpful during this initial dissectionas well. Estimating the redundant skin and capsule thathas stretched is sometimes tricky and can be facilitatedby knowing the ideal N-IMF relationships with specificvolume of implants. The new acellular dermal materi-als provide a significant adjunct and further reinforcethe soft tissues in minimizing further deformity, as wellas decreasing recurrent capsular contracture.

POCKET PREPARATION ANDCAPSULAR FLAP DISSECTION

1. The implant is manually displaced cephalad and anapproximate level of the new, revised, or planned loca-tion of the new IMF is determined and a capsulotomyperformed. The free edge of the capsule is left intact,and the redundant lower capsule below the fold isresected.

2. The new location of the IMF may be estimated withthe patient in an upright or partial upright position,with her implant or an implant trial in position andthe fold marked internally with methylene blue and a22-gauge needle.

3. If the patient has a concurrent capsular contractureor calcification, or at the surgeon’s discretion, theanterior capsule is resected to the inferior border ofthe pectoralis major muscle, or completely. If this isundertaken, strong consideration for acellular dermalsupport should be made, which will further defineand support the fold, support the weight of thedevice, decrease future stretch deformity, provideadditional coverage in the often thinned lower breastpole, and decrease circumferential capsule formation.

If there is no evidence of capsular contraction, cap-sulotomy at the apex of the pocket may be performedand the vascularized capsule used as an additional layerof support for the device. Dissection is then carried outsuperficial to the capsule to the lower pectoralis marginand acellular dermis sewn to the muscle border similarto using this material in a breast reconstruction model.

4. Pitfalls: These three complications are among the mostdifficult to treat in breast surgery. Every technique to de-crease recurrence and minimize or eliminate the defor-mity should be considered including exchanging salinefor gel devices, capsular flaps, or neosubpectoral pock-ets, and adding acellular dermal tissue. In addition, allmaterials do not have the same elasticity so it is impor-tant to understand the specific characteristics of thematerial you are using.

Figure 9-7

Pectoralis major m.

Acellular dermal matrix

Pectoralisminor m.

A B



5. Pearls: Adequate incision size is critical. When re-secting 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 theoriginal implant in position for the early portion ofthe dissection greatly facilitates the procedure. IdealN-IMF folds may also be estimated preoperativelybased on the final implant size chosen, specificallydetermining the distance on stretch.

CLOSURE

1. The standard inframammary closure may then be per-formed in three layers closing the superficial fascia witha running or interrupted absorbable suture such as 3-0Vicryl followed by a subdermal 3-0 Monocryl sutureand a running 4-0 Monocryl subcuticular suture as pre-viously described. The new 2-0 or 3-0 Monoderm quillsuture may also be used subcutaneously in a runningtwo-layer fashion, which expedites the closure. In thebottoming out deformity the deepithelialized dermismay also be used to support the closure.

2. Wound care—the incision is covered with steri-stripsor a sterile band aid gel strip that provides epithelialhydration and a waterproof barrier may be used.

SPECIAL TECHNIQUES

Capsular Contraction

The surgical approach and correction of capsular con-tracture is similar to those previously described and usedfor correcting wrinkling and rippling. The important dif-ference is in the pathology of the capsule. In general cap-sular tissue should be looked at as “pathologic” oftenformed by Biofilm or a subclinical infection and should beremoved with total capsulectomy or near total when pos-sible. Verses say in a stretch deformity where the redun-dant capsule may be used for further support. Witch cap-sular contracture the capsule should be removed (Figure9-8) and high consideration for replacement with an acel-lular dermis particularly in multiple recurrent capsules.The abnormal capsule may then be “replaced” with anacellular dermis as a pectoral extension similar to its usein breast reconstruction (Figure 9-9).

Dissection for Capsular Contracture CasesThe skin incision is made with a #15 blade scalpel andinitial dissection is carried through the dermis with elec-trocautery. For prior submuscular implants, with theoriginal implant left in position as long as possible withdissection carried down to the superficial breast capsule.Dissection is then initiated in the cranial direction and to

Cut edge of pectoralismajor m.

Implant

Free edge of capsule

Cut edge of capsule

A B

C DFigure 9-8



the caudal border of pectoralis major muscle. Dissectioncontinues deep to the muscle with all of the capsular tis-sue or as much as possible resected (Fig. 9-8A–D).

In the case of a prior subglandular implant, total cap-sulectomy with implant removal is recommended and asite change typically performed with or without additionof an acellular dermis as a pectoral extension.

Insetting and closure is performed as described abovein the Stretch deformity section.

*no pitfalls or pearls here . . . go right in to the Cap-sular flap section

Capsular Flap—Neosubpectoral PocketBackground: The capsular flap, or neosubpectoral pocket,is a powerful tool in revision breast surgery and should bea part of the surgical armamentarium of all plastic sur-geons. It is used in situations in which a patient has had aprior breast augmentation in the submuscular position,and is most helpful in patients with medial malposition(symmastia), inframammary fold or lateral malpositions. Anew space is made superficial to or on top of the priorbreast capsule and back beneath the pectoralis muscle, thecapsule is collapsed, and a new implant is inserted into anew partial submuscular virgin pocket.

1. Incision Planning: The prior incision if periareolar or anew inframammary incision is made ellipsing the priorscar. Again, an adequate incision length is imperativeto adequate visualization: a minimum of 7 cm.

2. Details of the Procedure: As previously discussed,keeping the prior implant in position as long as techni-cally possible is important. Dissection is carried downto the anterior capsular surface with Bovie cautery.Elevation of the subcutaneous space is then performedwith the aid of double-ended retractors. Upon reach-ing the inferior edge of the pectoralis major muscle, anew dissection plane between the capsular surfaceand beneath the muscle is made. Pushing down onthe capsule and underlying implant with a moistenedRay-Tec sponge and stroking the dissection plane

with the cautery in the blended coagulation modewith pressure and tension helps to develop the tissueplanes. Rotate back and forth medially and laterallywith adequate visualization; lighted retractors are crit-ical. Upon reaching the apex of the implant, capsulo-tomy near the IMF is performed and the implantremoved. If a ruptured gel implant is suspected, it ishelpful to preoperatively place a large OpSite orIoban sticky drape to avoid silicone contact with theskin.

Alice clamps may then be placed on the muscleedge, and the new pocket is completed cranially. Care istaken not to overdissect the neopocket, particularly if anew shaped, textured implant is to be placed. Resectionof redundant capsule at the fold is undertaken to keepthe capsule tight against the chest with minimal redun-dant or extra tissue. The new device is then placed andpositioned into the new partial submuscular pocketabove and on top of the prior anterior capsule.

3. Pitfalls: Early capsulotomy and removal of theimplant makes the surgical dissection more difficult.Using the cutting current versus coagulation modewill increase the chance of an inadvertent capsulo-tomy, dramatically affects the ease of the procedure ifa ruptured implant is present. Early overdissection ofthe new space defeats the purpose and power of theprocedure to hold the implant in position and helpavoid future malposition. If a severe capsular contrac-tion or calcification is present, this procedure shouldnot be performed and the capsule should be resected.

4. Pearls: This is a very powerful procedure to learn anduse. More advanced techniques include rotating the flapsfor coverage and using the posterior capsule or only par-tial portions of the capsule to define the medial or lateralborders versus elevating the entire capsular surface. If animplant is in the subglandular space, a portion of thecapsule may be retained for coverage but a completelynew submuscular pocket is made verses using a capsularflap or neosubpectoral pocket technique.

A BFigure 9-9



Subglandular Coverage for Wrinkling/Rippling

In cases where a patient will not accept a submuscularimplant or where there is no muscle from prior surgery orcongenital absence, there are some alternatives. This tech-nique may not produce as significant an improvement asthe pectoral extension, reconstructive technique but stillmay provide improvement. Again minimizing the inher-ent device wrinkling using an implant with a higher fillvolume will provide an advantage. In addition, the acel-lular dermis may be inset either prepectorally or intra-capsular, but sutured to the chest wall and placed onsome tension to provide for less visible wrinklingthrough the material versus what the onlay may provideon its own just from the thickness and barrier of thematerial itself. In these instances an 8 � 16 cm piece orlarger may be oriented vertically and positioned over the

device. The medial aspect of the breast typically is thethinnest and thus the material may be placed more medialto maximize coverage, although this may vary patient topatient.1. Pitfalls: There are not sufficient patient data to advo-

cate this approach but it may be beneficial in provid-ing some coverage and improvement in patients withmarked thinning. There are relatively few alternativesexcept for autologus tissue transfer or fat grafting.Simple onlay alone may not provide adequate cover-age or cosmetic improvement.

2. Pearls: Secure the acellular dermis to the chest wall toprovide a tenting effect. Drains and adequate fillingof the space on some tension are important to increaseadherence and integration and revascularization ofthe matrix material.



Malposition MEDIAL/SYMMASTIA

Implant malpositioning can be a source of significant defor-mity following breast augmentation. Malposition can besuperior, inferior, lateral, or medial to the breast mound.When malposition is medial to the mound, it is described bya special term: symmastia (Fig. 9-10).

line, and in the most severe situations, the left and rightbreast implants share a common pocket (Figs. 9-12A–F).

Thin and attenuated tissues put patients at risk forthis malady. Even mild forms of pectus excavatum cansubstantially increase the risk by allowing passive medialmigration due to the angle and forces upon the rib cage.On the surgeon’s part, excessive medial dissection or divi-sion of the pectoralis origins can be contributory.

The problem seems to be more frequently found withimplants that were too large for the patient’s breast, asdefined by published tissue-based planning systems. Sym-mastia also appears to be more commonly related to inci-sions that limited surgeon visualization, such as a peri-areolar incision in the setting of a small areola.

The surgeon should be alert to identify that the mostsevere symmastia cases frequently include concomitantinferior malposition.

Treatment options depend upon the current and pro-posed pocket location of the device (Fig. 9-13). If thedevice is subglandular, the problem is most expedientlyresolved with a conversion to a new partial retropectoralpocket (if there is concomitant inferior malposition) ordual plane (if tissue pinch at inframammary fold (IMF)�5 mm and without inferior malposition). Although onecould choose to allow the implants to remain in the subg-landular pocket with either a capsulorraphy or creationof a neosubglandular pocket, the ease, durability, andpredictability of a site change to a retropectoral pocketmakes that a frequent choice.

If submuscular already, options are remaining sub-muscular or creating a new subglandular pocket.Although converting to a subglandular pocket is tempt-ing, the surgeon should remind himself or herself of themyriad of advantages offered by the submuscular pocket,particularly for the patient with symmastia, in that fre-quently these patients are thin and benefit from tissuecoverage, and because the muscle almost by definition isno longer attached to the sternum.

If one does choose to move the implant to the subglan-dular position, they should be cautioned to leave a very

Figure 9-10

Symmastia can occur in a variety of severities. In itsmost mild, two separate implant pockets remain, but one orboth implant pocks cross the midline. (Fig. 9-11A–B). Inmore severe situations, presternal skin is tented at the mid-

Figure 9-11

BA


Steve

Inserted Text

et

Steve

Cross-Out

Steve

Inserted Text

C

Steve

Inserted Text

s


Figure 9-12 Patient with severe symmastia that was noted immediately after her primary augmentation. In her case, the implantpockets communicated over the sternum. She also had 3 cm of inferior malposition. She is shown corrected after creation of a neo-subpectoral pocket through the periareolar incision.

F

E

D

C

B

A



wide intramammary distance. For if there is a submuscu-lar symmastia, then by definition the pectoralis is nolonger attached to the lateral border of the sternum.Unless the dissection stops lateral to the sternum, onemay find the new subglandular pocket ultimately com-municating with the submuscular pocket that created thesymmastia.

Most frequently, tissue coverage is such a priority thatsubmuscular symmastia is retained as submuscular, eitherby leaving the implant in the existing pocket and closingoff its medial extent with a capsulorraphy or by creatingan entirely new pocket between the anterior capsule walland the overlying breast/muscle tissue, known as a neo-subpectoral pocket.

Capsulorraphy can be difficult in cases of symmastiabecause both the anterior and posterior capsular wallsare often very thin overlying the sternum, which is thearea in which the repair must be the strongest. The cap-sule overlying the sternum itself is particularly thin, andunlike capsule overlying costal cartilage, the sternum istoo thick to pass a needle through. Capsulorraphy alsodemands that sutures be placed in precise, regular loca-tions in order to create a smooth and accurate boundary,which is very difficult to do when tissues are thin andinconsistent.

On the other hand, the neosubpectoral pocket is anew pocket that is behind the muscle and gland, but infront of the old capsule. Its perimeter margins are definedby the dense adhesions between capsule and overlying tis-sue. The smoothness and extent of the pocket is createdsimply by surgeon dissection. Sutures are used to obliter-ate the old capsular space, but they can be placed at irreg-ular intervals, allowing the surgeon to choose locations inwhich the tissue quality is best.

Because the edges are not defined by multiple sutures,there is less puckering seen right after surgery, and gener-ally the result looks better sooner. There appears to beless discomfort, perhaps because of fewer sutures aroundthe sensitive chest tissues.

INCISION PLANNING

Symmastia can occur following transaxillary, transumbili-cal, periareolar, and inframammary approaches. Neosub-pectoral pockets for the treatment of symmastia have notbeen described with the TUBA incision. If the previous inci-sion was inframammary, then that incision is frequentlyused again. One distinct situation in which this does notoccur is when the old IMF incision was made too low, sothat it would, therefore, be impossible to use it to create aneo subpectoral pocket with a nipple–inframammary fold(N-IMF) distance shorter than its location would define.

If the previous incision was periareolar, and the are-ola is of adequate diameter to allow excellent visualiza-tion and access, then that is frequently used. Overall, theoperation is easiest with a large periareolar incision, asthe surgeon is dissecting “from atop the mountain,”looking down with excellent visualization and proxim-ity to the farthest margins of the pocket. Although theinframammary incision is always enlargeable, it cansometimes be difficult to see over “the equator” of theimplant (in such cases the implant is left in place forcountertension as long as possible, and then it isremoved and the dissection is continued without theimplant in place).

DISSECTION

1. Instruments: The critical instruments are a double-ended retractor, extended-tip electrocautery, and aspatula retractor with which to retract against theimplant and/or capsule.

2. Markings/landmarks: The goal is to reestablish thenative boundaries of the breasts. Occasional this canbe seen as a “double-bubble” overlying the malposi-tioned implant. More commonly, these borders aretotally distorted. The surgeon is left, therefore, withtwo means to make the markings: the sternum and theposition of the entire IMF from sternum to lateralbreast border that is suitable for the chosen implant.

Once the new implant size is determined (see sec-tion on Device Selection in this chapter), an IMFshould be marked from a distance to the nipple at 7cm for 200 cc, 8 cm for 300 cc, and 9 cm for 400 cc.These lines should be drawn onto the breast andblended to the lateral border of the breast and cen-trally to the lateralmost sternal border. Err on the sideof creating too wide of an IMD to ensure adequatepresternal skin with no implant deep to it. Mark eachinterspace at the lateral sternal border and ensurethat the proposed IMD is no narrower than it.

3. Details of Procedure: Either a periareolar or IMincision is made. Dissection is carried through thesoft tissue to the implant capsule, and dissectionoccurs between the anterior capsular wall and the

Figure 9-13



parenchyma, as if one were performing an anteriorcapsulectomy. When the capsule is thin, the dissectionis more difficult. This is often the case with enlargedpockets of symmastia (as opposed to contractedpockets, which are usually thick). Be patient and takecare not to make tears in the capsule, although solong as the disruptions are not so large that they fun-damentally destroy the ability to create a bona fidespace in front of it, then small rents are acceptable. Infact, they provide an opportunity for visualization ofsutures that tack the front wall of the back wall, andallow drainage of fluid from the collapsed implantspace.

The dissection is easiest in the lower area of thebreast where, gland in front of the capsule. As oneproceeds superiorly and starts dissection under themuscle, the dissection often becomes more difficult(Fig. 9-14). The capsule often becomes notably thin-ner and more adherent to the muscle than in areasbeneath the gland. Just slow down, and reposition theretractor and make good use of counter tension. If itproves impossible to stay in this plane and not dam-age the muscle or capsule, then one can make a longhorizontal capsulotomy, thereby allowing the moreinferior portion of the implant to be in the neosubpec-toral pocket and the superior portion to be within theold capsular pocket (Fig. 9-15).

All dissection should stop short of your expectedlimitations of the pocket; you should plan to enlargeit later, which can be performed easily and accurately(Figs. 9-16 and 9-17).

Then perform a capsulotomy of sufficient size toremove the implant. Plan your capsulotomy around

adjacent holes that were inadvertently made in thecapsule, or in such a location that you will have goodvisualization into the pocket of any areas where youwant to put in quilting sutures to sew the front cap-sular wall to the back wall to obliterate the old pocket

Figure 9-14 Dissection starts identically to a capsulectomy. Theonly difference is shown in Figure 9-16: dissection is intention-ally incomplete.

Elevated pectoralismajor m.

Newly created neopocket

Old pocket and capsule(implant removed)

Figure 9-15 The layers involved in this operation are demonstrated. Afterdissection anterior to the capsular front wall, the implant is removed, thefront wall is tacked to the back wall, and the implant is placed in the newlycreated neopocket.



Previous capsule suturedto posterior wall

Fusion of capsule tosoft tissue demarcatesthe perimeter of theneopocket

Figure 9-18 The agittal view of the patient in 9-17 showshow the neosubpectoral pocket can correct inferior malposi-tion. The dissection stopped at the desired inferior locationof the new pocket. The dense fusion of capsule to tissueholds this secure. In cases of weakened tissue. an ADM suchas Strattice(TM) has been used in this position as an onlayfor reinforcement.

Stop short of where youwant the pocket to endand adjust later.

Figure 9-16 The neosubpectoral pocket is a procedure thatmakes a smaller pocket. The dotted line indicates the bordersfor the new pocket.

Figure 9-17 The lavendar shaded areas represents where themedially and inferiorly malpositioned implant had beenlocated prior to repair with the neosubpectoral pocket.

(Fig. 9-18). A smooth implant will remove easily, butif it is an aggressively textured implant, use cautionwhen removing it, as adherence to the overlying cap-sule can lead to destroying your well-dissected cap-sule during removal.

A series of sutures is placed from within the oldcapsule between the front wall and back wall of thepocket. Although it is true that the pressure of theimplant on top of the capsule will help to compressand obliterate that space, since there will no longer beimplant over the sternum, there is otherwise nothingto press the old capsule and hence the skin flat onto

the sternum. Even where the implant is pushing downon the capsule, sutures may help to obliterate thespace, preventing seroma formation, and preventingshearing of the front wall relative to the back wall,which could allow shifting of the pocket and, there-fore, of the implant itself.

Prior to placing these sutures, some methodshould be employed to “freshen up” the surfaces ofthe capsule, such as rubbing it with a cautery scratchpad, desiccating with a cautery, or using a PlasmaJet.The old space should also be well-irrigated withantibiotic irrigation to reduce the likelihood of con-taminating the new implant pocket with pathogensfrom the old capsular space.

In areas in which the neo pocket does not extendas wide as the old pocket (medially with symmastia,and often inferior as well) (Fig. 9-19) the sutures mustbe placed from within the old pocket. But in areas inwhich there is dissection over the front wall, suturescan be placed from outside the front wall, taking bitesof the underlying posterior capsule. Unlike a capsulor-raphy in which sutures must be placed in a particularlocation, these are spread apart randomly and placed



until the surgeon is satisfied that there is a firm fusionbetween the front and back walls, forming a stablesupport for the posterior wall of the new capsule.

This is repeated on the other side, and thenimplant sizers are placed. Ideally, the pocket wouldhave been underdissected. Using the spatula retractorto move the implant, the cautery is used for small,precise, incremental enlargements until a pocket min-imally large to accommodate the implant is made.Very small amounts of this dissection can create largeshifts in the pocket, so these adjustments should bemade in the smallest possible increments.

An additional optional step at this point is tolaminate the repair with a strip of acellular dermalmatrix, such as Strattice. If the tissues are very thinand weak, as may be evidenced by multiple rentsfrom the initial dissection or failing to hold thesutures that had been placed, or if the new pocketwas inadvertently overdissected, sewing a strip ofStrattice appears to be very helpful.

A drain is placed, the pocket is irrigated withAdam’s solution, gloves are changed, the implants areplaced, and the incision is closed.

4. Pitfalls: Although not a pitfall per se, a disappoint-ment not uncommonly encountered is that somepatients want an implant that compromises thechances of successful correction. They may be disap-pointed if the implant is too small and they wouldcertainly be disappointed if the symmastia recurred;this must be discussed to absolute satisfaction preop-eratively.

Some women with extreme inferomedial sym-mastia have substantial skin excess and webbing thatbecomes revealed after the successful correction ofthe symmastia. Although the problem that led to theoperation may have been corrected, because of itslocation, this skin excess is extremely difficult if notimpossible to correct, even with substantial scars.Raising this as a possibility when it can be foreseenwould be prescient on the part of the surgeon.

If you do not secure the front wall to the backwall, the weight of the implant in the new precapsu-lar pocket can cause the front wall to shear inferiorlyrelative to the posterior wall. There is a tendency toadvance the anterior wall cephalad relative to theposterior wall, thereby inadvertently raising the IMF.

If you do not leave some openings in the anteriorwall, fluid could be trapped or a seroma could formwithin the old space.

The neosubpectoral pocket can fail to fix sym-mastia if any of the following occur: the implant is solarge that it re-creates the deformity by again stretch-ing tissues; if the new pocket itself is over dissected; ifthe capsule tears at its fusion point with the overlyingsoft tissue; or if the capsule itself tears substantiallysomewhere along the old anterior wall and therebyallows the entire pocket to migrate. Usually the cap-sular tissue is sufficiently robust such that this doesnot occur. Consider obtaining consent from patientsfor the use of Strattice to laminate the medial and/orinferior margins of the pocket if you suspect that thecapsular tissue might be too weak to support the bor-ders of the neosubpectoral pocket, and make a finaldetermination intraoperatively.

5. Pearls: This is not a “repair” so much as it is the cre-ation of a new pocket, the borders of which aredefined by the intimate adherence between capsuleand overlying gland/muscle. Once you overdissect,it is extremely difficult to place sutures and gainthe strength that the fusion alone provided. Inaddition, once the implant is removed and thefront wall is sewn to the back wall, the externalskin markings with which you were guiding yourdissection often appears to change in location. Sounder dissect, and expect to go back and finish offthe pocket with the sizer in place after the pockethas been obliterated.

Do not worry about creating little rents in thecapsule as you are dissecting, as these will serve asspaces from which air and fluid can leave the old cap-sular space. You can also use these to see the posteriorwall when placing quilting sutures, rather than plac-ing sutures through the anterior capsular wall andblindly taking bites of posterior wall. In fact, it is help-ful to create additional 3 or 4 mm “mini-capsulo-tomies” where you want to place your sutures to moresafely and strongly place the quilting sutures.

Old capsuleextends bilaterally

Figure 9-19 Axial view of the abdomen illustrates how theneosubpectoral pocket treated the symmastia. The excessivemedial extent of the pocket is collapsed and the front and backwalls are sewn together. The medial and lateral extends of theprecapsular dissection limit the medial and lateral borders ofthe new pocket.



need not to put stress on tissues that have proved them-selves to be weak, and he or she should not proceed unlessthe patient has accepted the implant size that the surgeonfeels is best for minimizing the chances of recurrence.

Both smooth and textured implants can be used.Smooth implants may have some advantages for ease ofinsertion and a lesser propensity to have palpable folds,but aggressively textured implants may be more likely toremain in place and not migrate out of position. There isno consensus of opinions about this choice, and texturingshould be discussed between doctor and patient.

Closure

The deep layer is closed with a waterproof layer of run-ning absorbable sutures, and the remaining layers areclosed according to the surgeon’s usual preference.

POCKET PREPARATION

Implant Considerations

Many of these patients developed their problem becausetheir breast implant(s) exceeded the weight and dimensionsthat could be supported by their tissue. Unless it is obviousthat there was overt overdissection and that the implantwas of the proper size for the patient, the implant sizeshould be reduced. In the ideal situation, one would lookback at original preoperative measurements to determinethe ideal size for the patient. When no records are avail-able, sometimes the implants size is determined intraoper-atively. Many patients with symmastia put pressure oneven the correcting surgeon to place an implant largeenough to reduce the likelihood of a recurrence-free repair.The surgeon must be insistent with these patients about the



Inframammary FoldMalpositionINCISION PLANNING

1. Although prior vertical or existing scars may be used,similar to other breast revision procedures, the inframammary approach is preferred in mostpatients. A minimum of a 7-cm-long incision is typi-cal to facilitate exposure and perform the procedurewell, particularly if an acellular dermal matrix is used(Fig. 9-20).

Definitions and Semantics

Stretch deformity of the lower pole, giving the appear-ance of “bottoming out” of the breast, is defined by anincrease from a preoperative nipple–inframammary fold(N-IMF) distance to postoperative distance, with the foldremaining in its exact position from the time of the pri-mary operation (Fig. 9-21).

Minimum 7cmincision

Old scar–stretchdeformity

New IMF

Figure 9-20

A B C D

Figure 9-21 A. Normal implant position. B. Fold malposition. C. Lower pole stretch deformity. D. Wrinklingand rippling.



A B

C D

Figure 9-22

This is different from a fold malposition whichoccurs when the implant drops down below the initialIMF location that was present preoperatively or set at thefirst operation. This does result in an increase in the newN-IMF distance; however, the fold itself, where the breastattaches to the chest wall, has dropped and the IMF scarrides up on the lower pole of the breast if an inframam-mary incision was previously used (Figs. 9-22A–D and9-23A–D). Both stretch deformity and fold malpositiongive the breast a “bottoming out” appearance which iswhy these definitions are preferable and more specific.

2. After defining the exact nature of the deformity,and these key relationships, incision planning isperformed to set the final incision in the IMF. Thenew implant size and shape may also play a part inthe new IMF position. These relationships ofimplant size range and ideal N-IMF have beendetermined. A minimum length of 7 cm incision isrequired and this length may be longer if a skinresection is planned. This is confirmed intraopera-tively with the skin at maximal stretch (see Fig. 9-20).

INITIAL DISSECTION

1. Instruments: Five specialized instruments are recom-mended for this procedure. These include a double-ended breast retractor, an implant spatula, a fiberopticnonserrated lighted retractor with smoke evacuationcapability, a monopolar hand-switching electrocautery,and a good overhead lighting or fiberoptic headlight(shown prior).

2. Markings/landmarks: The incision is made preciselyin the planned location of the prior IMF or idealplanned location based upon the new implant to IMFmeasurement guidelines (Fig. 9-24).

3. The length of the incision is somewhat dependent onthe style and size of implant. However, for these revision procedures and in particular when using acel-lular dermis as a support, reinforcement, or as a ham-mock or sling internally, the procedure can be likenedto operating through a “mail slot.” The greater thevisibility, the easier and more efficient the technique(Fig. 9-25A,B).



B

A

C D

Figure 9-23. Postoperative Photographs

Incision site

Figure 9-24

4. Details of procedure: The skin incision is made andinitial dissection is carried through the dermis withelectrocautery. Vessels encountered including per-forators are prospectively cauterized. Next, withthe implant left in position, dissection is carrieddown to the superficial breast capsule and the infe-rior extent of the malposed pocket is defined (Fig. 9-26).

5. Pitfalls: It is very common when addressing a compli-cation and performing a revision to create a newproblem or deformity while trying to correct orenhance another, that is, creating a fold malpositionwhile correcting a capsular contracture. The surgeonmust be cognizant of this with great attention to detailto avoid this problem. Accordingly, it is important todo everything we can to avoid another revision forthese patients. Standard revisions have a very highrecurrence rate, particularly for fold malposition, thusreinforcing the soft tissues with acellular dermis andfine attention to detail may be critical.



A

BFigure 9-25

Figure 9-26

Take care to accurately mark the patient in theholding area and then confirm these markings intraop-eratively prior to beginning the procedure. Push downon the implant with the patient supine to determine themaximum extent of the fold malposition deformity.

6. Pearls: Keeping the implant in position as long aspossible initially greatly facilitates the capsular dis-section. This is true when dissecting up to define thepectoralis major as well as defining the redundantcapsule that has descended below the IMF. In addi-tion, spatula retractor is particularly helpful duringthis initial dissection.

POCKET PREPARATION ANDCAPSULAR FLAP DISSECTION

1. The implant is manually displaced cephalad and anapproximate level of the new, revised, or plannedlocation of the new IMF is determined and a capsulo-tomy performed. The free edge of the capsule is leftintact, and the redundant lower capsule below thefold is resected to provide fresh virgin tissue.

2. The new location of the IMF may be estimated withthe patient in an upright or partial upright position,with her implant or an implant trial in position andthe fold marked internally with methylene blue and a22-gauge needle.

3. If the patient has a concurrent capsular contractureor calcification, or at the surgeon’s discretion, theanterior capsule may be resected to the inferior bor-der of the pectoralis major muscle. If this is per-formed, strong consideration for acellular dermalsupport should be made, which will further defineand support the fold, support the weight of thedevice to decrease future stretch deformity, in addi-tion to providing additional coverage in the oftenthinned lower breast pole. If there is no evidence ofcapsular contraction, capsulotomy at the apex of thepocket may be performed and the vascularized cap-sule used as an additional layer of support for thedevice. Dissection is then carried out superficial tothe capsule to the lower pectoralis margin, and acel-lular dermis sewn to the muscle border similar to use



of this material in a breast reconstruction model(Figs. 9-27 and 9-28).

4. Pitfalls: It may be difficult to properly determine thenew “ideal” IMF location. It may take multipleattempts to determine this position. Capsulotomyand capsulectomy may be performed at the incorrectlevel leaving too much redundancy (not a problem)or shorting, that is, not leaving enough capsule toredrape over the lower pole of the device. It is betterto leave too much capsule and make the capsulotomylower than you estimate initially and just resect moreor overlap the tissue swinging it inside the pocket. In

addition all acellular dermal materials have differentproperties. For instance, Strattice is much stiffer, lesselastic in comparison to Alloderm, so if this materialis used, it should not be overly tight or over-correctedbut instead the surgeon should see the final result andimplant position in the sitting position intraopera-tively (Figs. 9-28 and 9-29).

5. Pearls: Try using methylene blue to help you markand estimate the new IMF position and redefinethe fold. Place the final implant or a trial sizer inposition and sit the patient up to help determinethe new “ideal” fold position. Ideal N-IMF foldsmay also be estimated preoperatively based on thefinal implant size chosen, specifically determiningthe N-IMF distance on stretch.

CAPSULAR FLAP AND ACELLULARDERMIS SUPPORT INSERTION

1. The capsule, if preserved as an additional layer ofsupport, is then inset into the new IMF location afterthe final implant is placed. The acellular dermis isinset superficial to the capsular flap and further insetto support the new IMF.

2. Closing off the original redundant pocket in the priorarea of fold malposition is then performed, effectivelyeliminating the prior space. Multiple layer fascial andskin closure is then performed in multiple layers, over adrain which is brought out lateral to the incision. Finally,the patient is positioned upright on the operating tablejust prior to final closure to assure fold symmetry.

3. Pitfalls: If a trial implant or protected final device isnot used when suturing this material into positionalong the pectoralis border, bowstringing or over-tightening creating an overly flat appearance mayoccur. Some minimal stretch of the material will occur,dependent on the specific type utilized. Damage to the

Cut edge of pectoralismajor m.

Implant

Free edge of capsule

Cut edge of capsule

Figure 9-27

Pectoralis major m.

Acellular dermal matrix

Pectoralisminor m.

Figure 9-28

Figure 9-29



Figure 9-30 Figure 9-31

implant may also occur if not protected and withoutspecial attention made at closure.

4. Pearls: It is best to inset any acellular dermis an ini-tial the distance as far away as possible from theincision, generally the most medial or most lateralaspect. This can be set up with interrupted suturesplaced medially, centrally, and then laterally andthen run, or the surgeon may start laterally and runmedially (Figs. 9-29, 9-30, and 9-31).

CLOSURE

1. The standard inframammary closure may then beperformed in three layers, closing the superficial fas-

cia with a running or interrupted absorbable suturesuch as 3-0 Vicryl followed by a subdermal 3-0Monocryl suture and a running 4-0 Monocryl subcu-ticular suture as described previously. The new 2-0 or3-0 Monoderm quill suture may also be used subcu-taneously in a running two-layer fashion.

2. Wound care: The incision is covered with Steri-Strips or a sterile bandage gel strip that providesepithelial hydration, and a waterproof barrier maybe used.



HyperanimationDeformitiesImplants are frequently placed at least partially behindthe pectoralis major muscle for good reasons. The greatertissue coverage obscures the borders of the implant, mak-ing the breast generally look and feel less obviously aug-mented. There may be advantages in obscuring implantrippling and reducing the incidence of capsular contrac-ture, and it may help with mammography.

But there can be trade-offs. One of the most annoyingfor patients is the hyperanimation deformity (Fig. 9-32).It is indeed normal for even the nonoperated breast to

move with the arms and with strong contraction of thepectoralis. Some movement is normal and should there-fore be expected with any augmentation behind the mus-cle. This is something that patients should understandpreoperatively, and they should select this pocket choice ifthe trade-offs are acceptable to them. Studies have shownthat with adequate preoperative education and accuratedual-plane surgery.

In some patients, however, the movement can besevere and distorting. It is typically difficult to determinethe exact cause, but it may be some combination of anumber of factors. Intact or irregularly intact pectoralisorigins along the inframammary fold (IMF) can lead toinferior flattening with contraction and superolateralimplant movement. Division of the pectoralis off the

A

C

B

DFigure 9-32 This patient complains of excessively visibly implant edges and animation deformity on full contraction(D). After placement of Strattice (TM) between pectoralis and inframammary fold, the implant edges are less visible,and the animation deformity is reduced (H.)


Steve

Inserted Text

, reoperation for animation deformity is very rare.


sternum, even division one or two interspaces above themedial junction of the IMF with the sternum, can con-tribute to excessive inferolateral displacement. Thesepatients often have attachment of the caudal cut edge ofthe pectoralis to the undersurface of the gland, causing aninward pulling of the breast tissues with contraction,which is one of the worst deformities. This type of problemappears to be exaggerated by either planned or inadvertentexcessive dissection between the gland and superficial sur-face of the muscle, thereby allowing the muscle’s lowerborder a greater propensity to slide superior and attach tothe deep surface of the gland (Fig. 9-33). The scar thatbinds the muscle to the gland after dissection does notallow the normal small amount of gliding that occurs in thenon-operated breast. This problem is most severe after a

subglandular breast is converted to submuscular, as theentire muscle surface becomes adherent to the deep surfaceof the gland with scar, thereby preventing sliding betweenthe muscle and gland.

It remains enigmatic that seemingly the same operationcan result in significant hyperanimation deformities in onepatient and not in another. Certainly, any effects are morenotable in the very thin patient, but there must remain otherfactors that have yet to be formally elucidated.

The simplest solution to end hyperanimation defor-mities is to switch to a subglandular pocket. But there aremany advantages to the submuscular pocket, as statedearlier. And because many patients complaining of hyper-animation have very thin tissue, as a group they oftenhave the most to gain from the use of the submuscular

G H

E F

Figure 9-32



DISSECTION

Long retractors and long needle holders are essential forthis procedure.

1. Markings/Landmarks: The existing IMF ismarked. If it is malpositioned, a plan should bemade to correct it. Every effort should be made topalpate the caudal border of the pectoralis, anddots are placed along the border to trace its out-line. By having the patient repeatedly contract andrelax, the surgeon should be able to determine ifand how far superiorly the pectoralis has beenreleased from the sternum. This space should bedrawn out. This should be done during the initialconsultation so that the appropriate size of ADMcan be ordered (Fig. 9-36). These markings aredone again on the morning of surgery to aid in sur-gical planning.

2. Details of Procedure: Make a partial thickness inci-sion along the superior border of the old infra-mammary scar and dissect full thickness down tothe capsule through an incision along the loweredge of the scar (the upper edge of the incisionoften gets abraded with retractors during this pro-cedure), so use the scar to protect the edge; in theabsence of a previous inframammary scar, makeone at the appropriate distance from the nippleaccording to the implant size (eg, 200 cc, 7 cm; 300cc, 8 cm; 400 cc, 9 cm) in the deepest recess of theIMF.

Carry dissection down to the capsule. Begin a pre-capsular dissection as if you were going to perform acapsulectomy. Continue the dissection up until youreach the entire extent of the caudal border of the mus-cle. Dissect between the muscle and overlying gland justenough to free up the end of the muscle (Fig. 9-34A–B)this is no more than several centimetres.

Remove the capsule you have now freed up fromthe lower pole of the implant (Fig. 9-37). The implantis removed. Irrigate with Adams solution and stop allbleeding with electrocautery.

Gloves are changed and the ADM is broughtonto the field. Leave it large as it is easiest to trim itlater. Lifecell now makes Strattice in three sizes ofprecut elliptical shapes that are often ideal with littleor no trimming necessary. Draw on the skin the loca-tion of the caudal border of the pectoralis major mus-cle, and join this line with the inframammary fold.This will approximate the gap between muscle andfold that the acellular dermal matrix will bridge.There are many methods to sew this in place. Oneway is to rotate the ADM clockwise and counter-clockwise until it best fits your drawing of the defect.In the worst cases of animation deformity, the musclemay have been divided two or more interspaces alongthe sternum, so that the medial apex of the gap is not

Skin wrinkling Muscle fibers adheredto breast parenchyma

Figure 9-33 Three structures maintain the position of the infe-rior edge of the pectoralis: the inframammary fold origins, thesternal origins, and the attachments between the pectoralis and overlying gland. The inframammary fold origins are com-monly chosen to be released, and slight intentional disruptionsof the attachment between muscle and overlying gland areoften selectively by conservatively divided. But if these fibersare aggresively divided, or if the patient was ever subglandular,these fibersare no longer able to hold the inferior edge of thepectoralis caudally. Pectoralis rigins should never be dividedalong the alteral sternal border. As shown in this illustration, itallows significant superior malposition of the caudal border ofthe pectoralis and medial implant visibility and traction rippling.

pocket. What was only a deformity under the state ofsevere contraction can now be a worse deformity ofsevere implant visibility at all times, even when in repose.

In the case of inferomedial flattening with superolat-eral displacement due to strong and intact pectoralis ori-gins along the IMF, improvement can usually be madewith a release of these fibers. But if these fibers havealready been released, and particularly if the muscle isadherent to the overlying gland, something else needs tobe done. The use of an acellular dermal matrix to bridgebetween the caudal edge of muscle and IMF serves as apotent method for solving these problems.

INCISION PLANNING

The surgeon will need wide access to complete this oper-ation, so an inframammary incision is used unless thepatient has a very large areola with sufficiently thinparenchyma to allow the surgeon wide and clear visuali-zation and the ability to sew the ADM all along the lowerborder of the pectoralis and along the IMF.



A B

Figure 9-34 Dissect for just a centimeter or so along the superficial surface of the muscle so that theADM can overlap the muscle, so that the free edge of the muscle cannot scar up to the overlying gland.

Figure 9-35

Figure 9-36 A trapezoidal sheet of ADM is shown overlyingthe defect marked with dotted lines. In this drawing, there isabout one interspace of division of pectoralis off of thesternum. If the muscle is higher up, there will be a longer verti-cal component to fill along the sternum, and if it was notdivided off of the sternum, the muscle will meet the pectoralisat an apex.


Steve

Sticky Note

the comments that are now listed for 9-36 should be placed alongside 9-35.

Steve

Inserted Text

A contoured sheet of ADM is shown prior to insertion after a series of "parachute sutures" have been placed to orient the ADM. By putting tension on these temporary stay sutures, it helps the surgeon to sew the ADM into the desired position.


Figure 9-37 The ADM overlaps the edge of the pectoralis mus-cle so that the muscle cannot scar up to the overlying gland.

Figure 9-38 This drawing shows the gap between muscle andinframammary fold being closed far laterally. Usually, however,there is not enough ADM to completely cover the implant thisfar laterally. Improvement of animation deformity does notrequire significant lateral coverage.

an apex, but rather is the vertical distance along thelateral sternum between the IMF inferiorly and thelast fibers of the pectoralis muscle left intact superi-orly. Internal rotation of the ADM is helpful in thesecases. Then draw lines radiating from the edges of theADM out on to the skin surface. Place silk staysutures at each of these marks on the ADM, and pullthe suture from inside the patient to exit by the cor-responding hatch mark on the skin surface. Be surethat the sutures do not go through the muscle, but gobetween muscle and gland, so that when the suturesare pulled up, it brings the ADM into the body over-lapping the inferior edge of the pectoralis muscle.Start tacking this into place with interrupted sutures,stopping occassionally to place in a sizer. Expect toremove and replace sutures in order to get the ADMto lay smoothly. While you are doing this, be surethat the ADM has enough height to be successfulsewn along the IM without flattening out the lowerpole of the implant. If you will need a larger piece, it

is better to realize this now than after sewing it in.(Fig. 9-38). The sizer is then replaced and these suturescontinue along the inferior edge as it is trimmed. Thereis a tendency to over trim to make everything look toosmooth, but then when the patient stands up, thelower pole can be too tight.

Complete the closure until you have just as muchopening left as is necessary to remove the sizer andplace the final implant. Remove the sizer, again irrigatewith Adam’s solution and check for hemostasis, andplace a drain. Change gloves, place in the new implantthat has been soaked in triple antibiotic solution, andfinish the final closure of the pocket with great care toavoid damage to the implant.

A BFigure 9-39



3. Pitfalls: The most conspicuous pitfall is failing tomeet patient objectives for the procedure. Even inthe most successful operation to correct hyperanima-tion deformities, some motion will exist. Patientsmust be prepared for this preoperatively. In addition,this is an extensive operation that brings with it thepotential for new problems, such as asymmetry inIMF height and lower pole fill as a result of thesize/location/tightness/integration of the graft. Othercomplications specifically of the graft such as infec-tion and even its cost must be considered.

Technically, it is easy to place the graft too tight ifit is sewn in without a sizer under it; however, with thesizer under it, it is often difficult to see where to put thesutures, and even the sizer can be easily damaged.Therefore, one must be ready to frequently introduceand remove a sizer, assuring that the ADM can ade-quately expand to accommodate the implant until thesurgeon develops a good understanding of the interac-tion of the ADM and the surrounding breast tissues.

Seroma formation is a recognized complicationwith ADM, but the incidence can be reduced if drainsare left in until output is low.

4. Pearls: Because the graft material is expensive, it istempting to order a smaller piece. But be sure to have

larger pieces on hand in case the muscle is pulledhigher than you had anticipated preoperatively.

Make frequent use of the sizer while determininghow exactly to fit the ADM into the pocket.

Document clearly preoperatively that the patientunderstands that there will remain some postopera-tive animation and that she preferred this to creationof a submammary pocket.

IMPLANT CONSIDERATIONS

There is disagreement as to which implant works the bestin this situation. Some surgeons prefer a smooth implantthat will be malleable and mobile underneath the con-tracting muscle. Others prefer a textured implant, partic-ularly a highly cohesive one with an aggressively texturedsurface, so that it stays in place and mostly resists thedeforming effects of muscle contracture.

CLOSURE

Given the presence of a foreign body and the risk ofseroma formation, a running, watertight deep closureshould be made, followed by closure of the fascia andskin with the surgeon’s preferred method.

A BFigure 9-40


Steve

Sticky Note

figures 9-39 and 9-40 are not a part of this discussion...they may be part of brad's sections, but they are not part of this. either move them to the appropriate position in his text or eliminate them entirely

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Revision Breast Augmentation - dr teitelbaum · Chapter 9 • Revision Breast Augmentation 77 5. Pearls: Adequate incision size is critical. When re-secting additional skin for bottoming