Revision Breast Augmentation—Correction of Implant Malposition

Introduction

Breast augmentation is one of the most common procedures performed by plastic surgeons. In the United States alone, it is estimated that more than three million breast implants have been inserted for primary breast augmentation since 2005. It is recognized that breast implants are generally not once in a lifetime devices. Various implant outcome studies report reoperations or secondary surgery at rates as high as 36%. As a result, there has been a steady increase in the number of reoperations being performed on patients with breast implants. It is important that any surgeon involved in the management of women undergoing aesthetic or reconstructive surgery with the use of breast implants become familiar with techniques used in secondary surgery. The presence of breast implants guarantees at least one or more operations to replace or remove them over the course of a woman’s lifetime.

Having a defined and thoughtful approach to breast augmentation is important to minimize rates of reoperation. Multiple studies have described approaches designed to maximize outcomes and minimize the likelihood of complications and reoperations. Decision making should be based on optimizing outcomes and preventing problems, both early and long term. Focus is placed in four main categories: patient education, preoperative planning and implant selection, precise surgical technique, and a defined process for postoperative care.

Common causes for reoperation include capsular contracture, implant malposition, asymmetry, size change, and upgrades to newer types of implants. The incidence of each of these varies slightly based on the outcome study. ^, ^, Causes for reoperation can be classified into three main categories. These are summarized in Box 9.1 . Essentially, these are classified into: (1) problems related to the surgical procedure, (2) problems related to soft tissue changes, and (3) problems related to the implant. Understanding the true root of the problem is critical in designing an appropriate treatment plan. This chapter focuses on management of one of the most common indications for reoperation: implant malposition.

BOX 9.1

Classification of Causes Resulting in Secondary Surgery

Related to the Operation

Poor choice of initial procedure (implant versus mastopexy)
Selection of incorrect implant
Failure to minimize implant contamination
Failure to optimize soft tissue cover
Overdissection/underdissection of the pocket
Overrelease/underrelease of muscle
Traumatic pocket dissection
Iatrogenic implant damage
Postsurgical fluid collection

Related to Soft Tissue Changes

Attenuation of tissues
Development of ptosis
Stretch of lower pole
Atrophy of tissues
Breast tissue/glandular hypertrophy

Related to the Implant

Rupture
Capsular contracture
Malposition
Rippling
Implant edge visibility
Palpability
Rotation
Seroma
Double capsule

Indications and Contraindications

Most patients are candidates for revision breast surgery provided they have reasonable expectations. Often, previous surgery will have resulted in damage and deformity to the soft tissues that can be improved upon but not restored to normal. As stated earlier, any revision procedure has the potential for complications that can leave the patient with either ongoing or new problems. Patients must be prepared to accept the challenges of revision surgery and understand that there can be no guarantees of success.

Physical examination will focus on both abnormalities related to the implants and those related to the soft tissues. Previous surgery, scars, and soft tissue changes will increase the risks of infection, delayed healing, and tissue necrosis. Patients should be healthy, and any co-morbidities must be optimized before surgery. Given the elective nature of these procedures, active smokers should be avoided and patients must be counseled on the importance of smoking cessation before any revision surgery ( Figs. 9.1A, B and 9.2A, B ).

Fig. 9.1, (A) Synmastia, or medial malposition, in a patient with subpectoral implants and overdissection of the medial border of the pectoralis muscle. (B) Correction with downsizing of the breast implant and creation of a neosubpectoral pocket.

Fig. 9.2, (A) Inferior malposition in a patient with overrelease of the inferior origin of the pectoralis muscle and simultaneous circumareola mastopexy. The anterior pressure exerted from the mastopexy may predispose to the malposition. (B) Correction with inferior capsulodesis and suture repair and revision of areola scar.

Patients with compromised soft tissues, especially when a capsulectomy is indicated, may be best treated initially with implant removal only. The need for a capsulectomy adds significantly to soft tissue trauma and vascular compromise. This is particularly true with subglandular implants. Secondary surgery may be performed at a later date and include implant replacement, mastopexy, or soft tissue augmentation with autologous fat transfer. Fig. 9.3A–D shows a patient who underwent four procedures for recurrent capsular contracture. After a fifth recurrence, she opted for implant removal. This was followed with two sessions of external tissue expansion using negative pressure and autologous fat transfer.

Fig. 9.3, (A) Fifth recurrent capsular contracture. (B) After bilateral explantation and capsulectomy. (C) Immediately after external expansion and plan for fat grafting. (D) After second session of fat grafting.

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