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Prevention and management of complications following breast augmentation and mastopexy
Synopsis
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Breast augmentation is one of the most commonly performed aesthetic procedures in the US and abroad.
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Preoperative assessment should determine the appropriate approach including choice of implant, breast pocket (submuscular, subfascial, subglandular, subpectoral with dual plane) incision location (inframammary, periareolar, transaxillary, transumbilical) and the need to lower the inframammary fold.
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Implant selection has expanded over the past few years to include many variables including implant fill (saline or silicone), implant shell surface (smooth or textured), implant form (round or shaped), implant dimensions (width, size, projections), and implant cohesiveness (4th or 5th generation implants) with associated differences in form stability and implant softness.
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Inframammary fold positioning is critical to establishing optimal implant placement in the pocket.
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Surgical approach, implant choice and operative technique can impact the incidence of complications, including implant malposition and capsular contracture.
Introduction
Postoperative complications and unsatisfactory outcomes in aesthetic breast surgery are all too common despite our best efforts and the management of these issues can be often much more challenging than the original breast procedure. Therefore, providing optimal outcomes for patients requires efforts to prevent complications and poor outcomes through careful preoperative planning, expert operative execution and diligent postoperative management. The focus of this chapter is on the prevention and management of complications associated with aesthetic breast surgery, including breast augmentation, mastopexy and augmentation mastopexy. Whereas some complications occur shortly after surgery, such as infection or hematoma, other complications may occur many months or years after the surgery. These complications may be implant-related, such as capsular contracture or implant failure, or may be soft tissue-related, such as skin/nipple–areolar necrosis or ptosis. These complications may be secondary to surgical technique, but more often are associated with perioperative assessment and planning of the surgical approach, taking into consideration the patient’s soft tissue characteristics and desired surgical outcomes. This review will identify the perioperative decision-making and techniques that will minimize these early and late complications while at the same time providing a practical surgical approach to successful management of these adverse events.
Breast augmentation – complications and revisional approach
The risk of reoperation following breast augmentation has been reported to be at least 12% but more often up to 30–40%. The following are the most common complications incurred and includes the management of each.
Hematoma
The incidence of hematoma after a primary breast augmentation is approximately 1%. The best prevention is achieving meticulous hemostasis intraoperatively. Blind or blunt pocket dissection without surgery for hemostasis after should be avoided to limit the incidence of hematoma. Patients should likewise be counseled to avoid medications that increase bleeding or interfere with platelet function for at least 2 weeks prior to surgery. A hematoma is easily recognizable with a breast that is swollen, painful, bruised and exquisitely painful to palpation or often arm movement. Treatment includes reoperation with evacuation of the hematoma, hemostasis, pocket washout and drainage placement. Implant replacement is usually not necessary. Expectant non-operative management of a hematoma around an implant is discouraged as it can lead to prolonged healing, wound problems, infection and possible long-term issues of asymmetry and potentially a capsular contracture.
Infection
Infection rates for primary breast augmentation can approach 2%. It is well known the breast parenchyma and associated breast ducts harbor bacteria that can be introduced into the operative field or breast pocket. Prevention is key and many operative maneuvers can assist in minimizing this possibility. Current recommendations are for skin preparation with preoperative cleansing and surgical preparation with chlorhexidine, which covers most organisms including methicillin-resistant staphylococcus aureus (MRSA). Likewise, perioperative antibiotics and antibiotic pocket irrigation reduce implant contamination and possible infection. Insertion funnels or barrier membranes or any effort at a minimal-touch technique can reduce contamination, infections and potentially capsular contracture. The standard treatment includes operative exploration, culturing, irrigation and debridement of the pocket with drain placement. In most incidences, the implant is removed during this procedure and re-augmented 6 months later. There is the possibility of implant salvage with prolonged antibiotic therapy if the patient is clinically stable and the infection is limited, but failure of a salvage procedure would mandate implant removal.
Sensation changes
Alterations in nipple sensitivity can manifest as either hypoesthesia or hyperesthesia and are often the result of traction injury, bruising, inflammation or possibly even injury to the lateral intercostal cutaneous nerve that enters the breast laterally on the deep surface just above the pectoral fascia. Although the major innervation is the 4th, there is some overlap from the anterior and lateral branches of the 3rd and 5th intercostal nerves. There is evidence that nipple sensitivity changes are no more likely with a periareolar incision when compared with an inframammary incision. The most common cause is aggressive pocket dissection laterally, especially with sharp dissection, with injury to the intercostal nerves.
Deflation and implant rupture
It is important to inform breast augmentation patients that breast implants do not last a lifetime. Any disruption of the outer shell of a saline implant leads to complete failure of the implant with the saline leaking out into surrounding tissue and is harmless. Saline implant failure can be associated with trauma or a spontaneous leak that involves either fold fatigue on the shell of the implant or valve incompetence. Silicone implant rupture rates have been quite variable between devices and failures increase with the age of the implant. The rupture rates have varied from 10% to 25% at 10 years based on implant type. The 5th generation silicone gel implants have more cohesive gels and the silicone is less likely to egress from the implant shell leading to a much lower rupture rate than early 4th generation devices. MRI imaging or high-definition ultrasound is currently the diagnostic techniques of choice to discern a silicone implant rupture and is part of the new directives from the FDA.
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