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Fig. 24.3 Secondary Breast Augmentation 3months postop
R. C. Ribeiro et al.
On the other hand, the change to a smaller implant causes less inconvenience in
the sense of creating “more space,” a new prosthesis can be included or not, associated with the remodeling of the mammary gland, with the subglandular or dual
plane being preferred.
When the patient is well educated about contemplating her desire, along with her
physical characteristics. Implant size is as much as patient’s choice when she
chooses to tell the surgeon to select the size that is best for her tissues as when she
chooses to tell the surgeon a specic size.
Rippling
Rippling consists of the visible and/or palpable presence of ripples from the implant
capsule. Rippling is probably the most distressing of all breast implant issues for
patients (Thorne etal. 2013).
Breasts most prone to visible rippling are those with inadequate tissue coverage
(e.g., when pinch thickness of the skin and subcutaneous tissue superior to the
breast parenchyma is less than 2cm) or when pinch thickness at the inframammary
fold is less than 0.5cm. Breasts with preexisting ptosis and those that are susceptible to postoperative ptosis are also prone to rippling. These situations should be
identied preoperatively. No type of breast implant can compensate for inadequate
tissue coverage, and deformities that occur are largely uncorrectable. Therefore,
the priority at primary augmentation is to maximize coverage and avoid tissue damage.
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All the factors mentioned above can coexist and lead to permanent tissue
damage. Thus, thin, weakened, stretched, and damaged tissues are responsible
for the occurrence, severity, and difficulty in correction of many of the common reasons for reoperation. The same minor malposition or capsular contracture which would not be visible under thick tissue and tight skin can be quite
visible under damaged tissue. Rippling is rarely an issue with good tissue coverage but becomes one when tissue is thinned. Finally, any problem that
requires correction is more problematic to correct when tissues are thinner
or weaker.
Both the surgical act of dissecting a pocket for a breast implant and the longstanding presence of an implant can cause atrophy of breast tissue. Prudent implant
selection and exacting surgical technique can help preserve tissue integrity and
minimize long-term parenchymal atrophy (Fig.24.4).
A breast implant that stretches the breast envelope as much as would lactation
can be anticipated to permanently stretch and alter breast tissue. Highly projecting
implants place more pressure per área than a wider implant of the same volume. If
width is held constant, highly projecting implants can be nearly twice the volume
and weight, thereby placing substantially greater pressure on the rib cage as well as
the soft tissue. This causes parenchymal atrophy, thinning of subcutaneous tissues,
thinning and stretching of skin, loss of skin elasticity, rib cage deformation, and loss
of sensation (Thorne etal. 2013).
These tissue changes can result in rippling, skin stretch requiring mastopexy, and
bizarre animation deformities (Thorne et al. 2013). Such problems are often not
correctable, and attempts to mask them with highly cohesive implants, an acellular
dermal matrix, and fat injections all result in imperfect corrections which are expensive and pose their own risks and drawbacks.
Fig. 24.4 Rippling
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A worrying factor is when there is a very thin scratch, usually less than 5mm,
which results in serious complications of formation and various complications with
local and systemic infection, which exists of breast tissue and tissue retraction.
Thus, here are alternatives to the challenging cases and examples proposed above,
demonstrating our experience with capsule graft, mesh or even free tram for
selected.
R. C. Ribeiro et al.
Capsular Graft Technique
A breast implant capsule forms as a physiological response to the foreign material
(Persichetti etal. 2014) and consists of brous connective tissue, mainly broblasts
and collagen brils (Basseto et al. 2010). Previous reports have described their
application as grafts or aps (Yoo and Lee 2010; Gargano etal. 2002), considered
as good material for reinforcement, especially to address breast implant-related
problems in breast reconstruction (Persichetti etal. 2014).
The concept of this technique is to use a capsule with graft to replace the mesh
or acellular dermal matrix (ADM) for secondary aesthetic breast procedures where
some situations become a complex and challenging scenario, and also as a lower
cost alternative. When replacement from the subglandular to submuscular plane is
indicated, muscular reinforcement is mandatory. During the surgical application of
this practice, it is important to take advantage of the breast pocket concept by adapting the skin envelope of the breast in order to reshape it (Baxter 2016).
To make use of this technique we must follow some criteria: thin tissue coverage,
exchange of the implant by patient’s request (older generation implants), malposition of implants, capsular contracture, and rippling. It is not recommended to perform this technique with patients affected by late or recurrent seroma and infection
of the breast pocket were excluded. Intraoperative exclusion criteria applied for
capsules with these characteristics: thick, brous, calcications, granulomas and
identied rupture of the implant or presence of seroma (Ribeiro and Arduini n.d.).
Surgical Technique
Starting from the incision previously proposed according to the surgical plan, a total
capsulectomy is performed with en bloc resection of the implant and a rigorous
hemostasis was conducted. Defatted capsule reverting and immersed in saline solution with a double antibiotic solution (1g cefazolin +80mg gentamicin). The new
breast pocket was washed with saline solution, hydrogen peroxide and the same
antibiotic solution (Ribeiro and Arduini n.d.).
It should be noted that re-approaches should, in most cases, be accompanied by
replacement of the prosthesis due to the great chance of contamination of the old
prosthesis, regardless of the size change or not.
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Next, the implant’s plane replaced from subglandular to submuscular due to
thinning of the tissue, a piece of capsule graft sutured on edges of the pectoralmajor
muscle with absorbable suture (VylcrilR 3–0) to expand the breast pocket, with the
inner face of the capsule in direct contact with the implant. On the other hand,
where the implant is placed in the subglandular plane because there is appropriate
thickness of the tissue, the graft proposed for reinforcement in the prevention of
deformities (Ribeiro and Arduini n.d.). With this technique, all the harvested capsular grafts were viable to obtain complete coverage of the breast contour
deformities.
In this study, it was observed complete integration of the graft and better
coverage of the implant, corrections of retractions and rippling, as well as tissue expansion in the subpectoral plane when the change of plane was performed. No complications or new episodes of contracture were observed and an
aesthetic improvement and higher degree of satisfaction was reported by the
patients.
The capsule graft seems to be an excellent coverage reinforcement mechanism in
aesthetic breast revision using implants. Because the capsule is autologous tissue,
there is no additional cost in contrast to the use of ADM or synthetic meshes (Neto
and Gebrim 2019). Thus, the capsule graft does not generate rejection, it fully integrates with the patient’s tissue, in addition to providing reinforcement of the structures in the above-mentioned tissues (Fig.24.5).
Autologous material such as capsule graft or aps and fat grafting can be useful
in combination for recreating a stable breast implant pocket (Wessels etal. 2014;
Bogdanov-Berezovsky etal. 2013) and still meet the criteria of suitable materials.
a1 a2 a3
bcd
Fig. 24.5 Intraoperative view (a1/a2/a3) Capsule suture, (b) Newly created breast pocket; (c)
Capsule reinforcement and implant replacement (d) Pocket closed
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R. C. Ribeiro et al.
Mesh Graft
As shown with the capsule graft, the use of synthetic mesh also proved to be a viable
and more economical alternative to reinforce the submuscular pocket and implant
positioning, compared to the use of the acellular dermal matrix, due to the high cost.
The difference in relation to the capsule graft is its quality, which must be discarded,
following criteria such as: brotic and calcied capsule, silicone extravasation, contamination of the site, suspicion or diagnosis of BIA-ALCL. Given these scenarios,
the use of synthetic mesh becomes a viable alternative (Fig.24.6).
Complete coverage of the prosthesis by a submuscular pouch, in order to prevent
implant exposure in the event of an eventual skin/wound dehiscence, has been
shown to be quite effective and without signicant changes in complications (Billon
etal. 2019).
Synthetic meshes are non-biological materials that have been introduced and are
available in absorbable materials: Vicryl® (Ethicon Inc., USA), SeraGyn® BR
(Serag Wiessner, Germany) and TIGR® Matrix (Novus Scientic, Uppsala,
Sweden); or partially absorbable: ULTRAPRO® (Ethicon Inc., USA) and TiLOOP®
Bra (Pfm Medicalis, Germany).
The use of synthetic meshes in surgery has already been widely studied, proving
to be a safe, biocompatible, hypoallergenic material with a low rate of complications (Gschwantler-Kaulich etal. 2018). Therefore, the use of these materials can be
a good substitute for dermal matrices in surgeries.
Fig. 24.6 Complete
coverage of the implant in
a synthetic mesh reinforced
pocket
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Surgical Technique
A pectoralis major submuscular pouch is dissected respecting a minimum of 1cm
of tissue thickness and of good quality. The inferomedial edge of the pectoral muscle (up to the second intercostal space) is elevated for placement of a silicone mold.
The synthetic mesh (mesh) was sutured to this edge of the pectoral muscle, along its
entire lower course up to the inframammary fold.
The size of the subpectoral pocket is calculated using the desired implant volume
and the patient’s anatomy. A mold of the desired implant volume is then inserted
into the partial submuscular pocket to guide the size of the serratus anterior muscle
fascia that will have to be lifted to accommodate the lateral portion of the implant,
where the mesh will be sutured. After choosing the implant, it was introduced under
the synthetic mesh, this material being xed (with Vicryl® 2-0 suture thread) laterally at the level of the axillary line anterior to the dissected fascia of the serratus
anterior muscle and up to the inframammary fold in the desired position. Two suction drains were placed, one in the submuscular pouch and the other in the subcutaneous tissue, through separate cutaneous accesses, followed by closure of the
surgical wound in layers .
Studies with the placement of implants with full muscle coverage show complication rates of up to 40%, mainly in relation to poor implant positioning,
asymmetry of the submammary crease and capsular contracture (Hansson etal.
2020). Therefore, the limitations of this technique are based on a restricted sub-
muscular pocket, which prevents the placement of larger-volume implants and
makes it difcult to create a natural breast and a dened submammary crease.
The use of the mesh assists in the expansion of the pocket and better control of
the positioning of the implant, as well as a greater expansion of the lower pole of
the breast.
Conclusion
The only unequivocal endpoint assessing the quality of breast augmentation is the
revision rate. Fortunately, the steps that reduce reoperations also create more beautiful breasts. The opposite of a malpositioned implant is an ideally situated implant;
the opposite of a contracted capsule is a soft capsule, and so on.
The plastic surgeon’s priority is to maximize preservation of tissue and prevent
reoperation. This approach will simultaneously reduce her chances of facing the
risks, costs, and emotional distress of another operation and maximize the likelihood of an optimal aesthetic result (Thorne etal. 2013).
The techniques mentioned above proved to be very effective in challenging scenarios such as secondary mammaplasties.
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R. C. Ribeiro et al.
References
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Persichetti P, Lombardo GAG, Marangi GF, Gherardi G, Dicuonzo G. Capsular contracture and
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Persichetti P, Segreto F, Pendolino AL, Del Buono R, Marangi GF. Breast implant capsule aps
and grafts: a review of the literature. Aesthetic Plast Surg. 2014;38(3):540
Basseto F, Scarpa, Caccialanza E, Montesco MC, Magnani P (2010) Histological features of peri-
prosthetic mammary capsules: silicone vs poliurethane. Aesth Plast Surg 34:481-485
Yoo G, Lee PK (2010) Capsular aps for management of malpositioned implants after augmenta-
tion mammoplasty. Aesth Plast Surg 34:111-115
Gargano F, Moloney DM, Arnstein PM.Use of a capsular ap to prevent palpable wrinling of
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Baxter RA.Internal bra: a unifying solution for reconstructive and aesthetic breast surgery issues.
Plast Aesthet Res 2016;3:3-7
Neto MS, Gebrim LH.Capsular Flap for Implant Coverage in Breast Reconstruction Following
Nipple-Sparing Mastectomy in Women With Previous Breast Augmentation. Plastic Surgery
Case Studies. 2019. 5: 1-3.
Wessels L, Murphy S, Merten S.The capsular hammock ap for correction of breast implant pto-
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Bogdanov-Berezovsky A, Silberstein E, Shoham Y, Krieger Y. Capsular ap: new applications.
Aesthetic Plast Surg 2013;37:395-7
Billon R, Hersant B, Bosc R, Meningaud JP. Acellular dermal matrix and synthetic mesh in
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0/2000656X.2019.1704766
Chapter 25
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Basic Science/Disease Process
RicardoCavalcantiRibeiro, LuisFernandezde Córdova,
andAnaBeatrizArduini
Abstract Reduction mammoplasty, as the central purpose of this chapter, aims to
elucidate topics such as anatomy focused on plastic surgery, psychological aspects,
safety in surgery, and, of course, the main techniques. Surgery for breast hypertrophy is one of the most performed in plastic surgery, and more than 100 techniques
have been reported in the last century, aiming for a safer procedure, avoiding or at
least decreasing complications, and obtaining breasts with natural shape, proportional volumes, long-lasting results, and minimal scars that challenge creative
ability.
Keywords Basic science · Disease · Evolution
Reduction mammoplasty, as the central purpose of this chapter, aims to elucidate
topics such as anatomy focused on plastic surgery, psychological aspects, safety in
surgery, and, of course, the main techniques. Surgical treatment of breast hypertrophy is one of the most common surgical techniques performed in our eld, with
more than 100 techniques reported for reduction mammoplasty in the last century,
we as plastic surgeons aim for a safer procedure, that avoids or at least decreases
complications, and obtains natural shaped breasts with proportional volumes, longlasting results, and reduced scars, which is a real challenge for our artistic creativity.
R. CavalcantiRibeiro (*) · L. F. de Córdova
Plastic and Reconstructive Surgery, Federal University of the State of Rio de Janeiro,
Rio de Janeiro, Brazil
Carlos Chagas Institute, Rio de Janeiro, Brazil
Plastic and Reconstructive Surgery, Global Plastic Surgery, Rio de Janeiro, Brazil
e-mail: rribeiro@centroin.net.br
A. B. Arduini
Plastic and Reconstructive Surgery, Mário Kroeff Hospital, Rio de Janeiro, Brazil
Switzerland AG 2023
J. M. Avelar, R. Cavalcanti Ribeiro (eds.), Body Contouring,
https://doi.org/10.1007/978-3-031-42802-9_25
385© The Author(s), under exclusive license to Springer Nature
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R. CavalcantiRibeiro et al.
Etiology of breast hypertrophy is unknown, but it can be the result of an atypical
response of the breast to circulating estrogens, causing breast tissue proliferation.
There are hypertrophy and brotic changes of the fat tissue elements, but the glandular tissue remains with little change. Most women with breast hypertrophy have
normal levels of estrogen circulation, as well as normal numbers of estrogen receptors in breast tissue. It usually starts at puberty or postpartum, and there is no evidence for hormonal therapy.
Virginal hypertrophy usually affects girls between 11 and 16 years, presented as
a fast-growing breast reaching a degree of gigantism after menarche. This type of
hypertrophy may be unilateral or bilateral, without evidences of hormonal changes.
Conceptually, we can classify breast hypertrophy according to the predicted volume, as shown in Table25.1. There are varying denitions of what is an excessive
breast tissue, such as when it exceeds approximately 3% of the total body weight.
According to the literature, gigantomastia is considered when breast tissue removal
is over than 1000 g from each breast, but this number can change depending on the
references.
Breast are composed of mammary parenchyma, which contains glandular tissue
divided into lobules, adipose tissue, Scarpa’s fascia with its supercial and deep
layers, Cooper’s ligaments, Spence’s tail, the nipple-areola complex (NAC), and
lactiferous ducts, in addition to anatomical references. These elements add up to
maintain the breast structure and give the nal appearance of the breast.
In addition, another important parameter is the triple blood support—based on
the perforating branches of the internal thoracic artery (60%), the lateral thoracic
artery (30%), and the anterior and lateral perforating branches of the intercostal
arteries (10%)—which is the main reference for making the aps discussed in this
chapter.
Thus, size, symmetry, proportion, and location of the breast, as well as its reference points on the chest wall, provide the aesthetics of the breasts in addition to
well-dened signs of breast beauty such as conical shape with the areola at the apex.
It is necessary to have a precise knowledge of anatomy in order to choose the
most suitable technique for each case.
Table 25.1 Classication of
breast hypertrophy
Breast size Breast volume (cm3)
Ideal 250–300
Small hypertrophy 300–600
Moderate hypertrophy 600–800
Big hypertrophy 800–1000
Gigantomastia >1000
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Diagnosis/Patient Presentation
The breasts are a sign of femininity and a sexual organ of high importance for
women. During the last decades, the expectations of women regarding the aesthetic
and functional aspect of their breasts have increased signicantly. In the case of
women interested in having a breast reduction, besides a large spectrum of indications, the main motivations are function, form, and emotional issues related to
self-esteem.
Generally, patients who are looking for this surgery have very specic symptoms, such as shoulder pain, headache, neck pain, shoulder groove (bra mark),
kyphosis, inappropriate posture, intertriginous rash, and even neurological symptoms such as ulnar paresthesia. The compression of the brachial plexus between the
coracoid process and the pectoralis minor due to the posture of bending the shoulders forward explains the paresthesia. On physical examination, in addition, we can
nd signs of fungal infection or even secondary bacterial infection in the inframammary folds.
We must analyze very well the psychical aspect, in which the women’s selfcondence is usually affected, not only in self-image—they are not beautiful,
socially accepted, and have difculties nding partners or engaging in sexual activity—but also difculties in nding suitable clothes, playing sports, and socializing,
and sometimes making them with withdrawn personalities. If pathological disturbances have been suspected, a psychological consultation is suggested to determine
the causes and treatment, if possible, prior to surgery.
Before venturing into this type of surgery, the plastic surgeon must be aware of
the following factors that will inuence the outcomes.
Breast Size
The choice of technique should be performed according to the degree of hypertrophy. No specic bra size should be promised.
Skin Type
While in younger women the skin is more tense and elastic, in multiparous women,
older women, and those with the presence of stretch marks, the extension of the scar
and the ability of the skin to retract will inuence the outcome of the surgery.
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