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24 Capsular Contracture: Etiology andTreatment Options
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24.9 Complications
The complications that can result from a partial or complete
capsulectomy surgery are bleeding, swelling, infection, pain,
loss of sensation, loss of tissue, asymmetry, damage to nerves
and vessels, pneumothorax, and recurrent encapsulation.
Pearls and Pitfalls
1. To minimize bleeding the tissue surrounding the capsule
is injected with tumescent uid containing saline, lidocaine, epinephrine, and tranexamic acid.
2. Use Blunt dissection with an Iconoclast spreader and
Sharp with Bovie cautery.
3. The rst assistant should retract the tissues away from the
capsule with two long retractors such as Deaver and
Richie to help dene the plane between the normal tissue
and adherent capsule.
4. If the capsule is in the submuscular plane and adherent to
the ribcage, it may be detrimental to perform a complete
capsulectomy and certain portions of the capsule may
have to be left behind.
5. If the capsule is in the pre-pectoral plane care should be
exercised to avoid damage to the underlying muscle or
over thinning tissue anteriorly.
6. Careful hemostasis is achieved and in majority of cases a
drain is placed until drainage is less than 25cc per day.
The patient has to stay on antibiotics until removal of the
drain.
7. Multiple capsulectomies can lead to loss of tissue, damage to the underlying structure like the muscles, nerves,
vessels, and loss of support. The surgeon must weigh the
risks versus the benets of performing a complete
capsulectomy.
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Corrective Breast Surgery After
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Augmentation, Lift, andReduction
MarcoRomeo andGuillermoBlugerman
25
25.1 Introduction
Breast secondary surgery often comes after cosmetic procedures due to various factors: high volume of surgeries, open
market to both experienced and rookie surgeons, the high
expectations of esthetic results by the patients, and unexpected complications which are part of our life as surgeons.
Solving breast deformities is not an easy task but everyone who embraces breast surgery should be able to prevent
and deal with both one’s own and other’s deformities.
In this chapter we wish to explain how to deal with the
most common post-surgical deformities, how to prevent
them, and how to treat them once established.
25.2 Capsular Contracture
Capsular contracture (CC) is an event every breast surgeon
must be ready to deal with being the most frequent implant
related complication (Headon etal. 2015), ranging from 1%
to 20% according to different studies, despite more accurate
research set incidence at 3.8%.
According to Baker, CC has been divided into four grades:
• Grade I: The breast is normally soft and appears natural in
size and shape.
• Grade II: The breast is a little rm, but appears normal.
• Grade III: The breast is rm and appears abnormal.
Supplementary Information The online version contains supplementary material available at
M. Romeo (*)
Romeo Aesthetic Group, private practice, Madrid, Spain
e-mail: Doctor@drmarcoromeo.com
G. Blugerman
Centro Medico ByS, Buenos Aires, Argentina
https://doi.org/10.1007/978- 981- 99- 3726- 4_25.
• Grade IV: The breast is hard, painful to the touch, and
appears abnormal.
Usually, grade 1 and 2 do not require treatment while 3
and 4 do.
25.2.1 How toPrevent
While CC is not a completely understood nor solved complication, we know how to reduce the incidence by following
the 14 step plan of Adams (Adams etal. 2017) (Table25.1).
25.2.2 How toCorrect
1. Grade 3 requires softening of the breast, symmetrization
and correction of rippling when present. The most conservative and effective treatment is subcutaneous lipoll-
Table 25.1
Use intravenous antibiotic prophylaxis at the time of anesthetic
induction
Avoid periareolar incisions
Use nipple shields to prevent spillage of bacteria into the pocket
Perform careful atraumatic dissection to minimize devascularised
tissue
Perform careful hemostasis
Avoid dissection into the breast parenchyma
A dual-plane pocket has anatomic advantages
Perform pocket irrigation with correct proven triple antibiotic
solution or betadine
Minimize skin-implant contamination
Minimize the time of implant opening, reposition, and replacement
of implant
Change surgical gloves prior to handling the implant. Use clean or
new instruments that were not used in the pocket dissection
Avoid using a drainage tube, where possible
Use a layered closure
Use antibiotic prophylaxis to cover subsequent dental or surgical
procedures that produce bacteremia and have lifelong follow-up
Steps to prevent capsular contracture
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
M. Thomas, J. D‘silva (eds.), Manual of Cosmetic Medicine and Surgery, https://doi.org/10.1007/978-981-99-3726-4_25
383
384
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ing. There are several ways to harvest and perform
lipolling, from centrifugation to several ltering devices.
The author’s preferred method is gravitational decantation or mechanical ltering like Puregraft®.
2. Grade 4 requires complete capsulectomy, in case of suspicious or known implant rupture, “en-bloc” capsulectomy is highly recommended. Change of plan is
mandatory to submuscular/dual-plane with the use of
microtextured gel-lled or polyurethane prosthesis, not
high-textured nor smooth implants are recommended.
ADM insertion has proved to contribute to reduced capsular contracture but carries higher risk of seroma and
infection and increases the cost of the procedure, lipolling remains the most reliable option.
M. Romeo and G. Blugerman
25.2.3 Pearls ofWisdom
Extreme care must be taken to avoid implant perforation during lipolling, a spare implant must be available at all times.
Lipolling has to be performed before nal implant placement (we can use a sizer, meanwhile), to avoid implant damaging and accidental lling of the pocket (Video 25.1).
Care must be taken to avoid pleural damage when cutting
the capsule off the ribs, a periosteal elevator is a useful tool
to perform a clean and safe dissection (Fig.25.1).
Polyurethane implants should be positioned lower than
silicone ones as they do not slide caudally as the latter.
Implant removal and mastopexy with Ribeiro’s auto prosthesis is a desirable option when a thick glandular tissue is
still present. Careful dissection of the lower pedicle has to be
performed at the beginning of surgery before implant
removal (Fig.25.2).
Fig. 25.2 Glandular ap dissected before implant removal
25.3 Double Bubble Breasts Vs
BottomingOut
Double bubble and bottoming out can be confused and represents two deformities with similar iatrogenic cause but
with anatomical differences as follows.
25.3.1 Anatomy ofDouble Bubble
Double bubble occurs if breast implant is displaced below
the old inframammary fold. The risk of this deformity is
higher when the patient presents with a very thick inframammary fold, leading to this double bubble perception, one of
them would be the implant and the other bubble would be the
original breast parenchyma. Also, the risk is much higher in
the submuscular plane since the risk of inferior displacement
of the implant is higher.
25.3.2 Anatomy ofBottoming Out
Fig. 25.1 The costal plane is exposed after complete capsulectomy. A
periosteal elevator is useful to perform a safe dissection and avoid pleural perforation
The mechanism of this complication is similar to double
bubble deformity since there is a displacement of the implant
below the old IMF. Nevertheless, knowing the difference
with double bubble deformity is very important. When bottoming out occurs, the implant is displaced below the old
IMF, but the integrity of the IMF is not preserved, while in
double bubble old IMF is not severed, resulting in the double
mound appearance.
The same problem can occur during mastopexy for instability of the IMF, abdominal skin steal, and a tent-effect with
unpleasant esthetic effect (Figs.25.3 and 25.4).
25 Corrective Breast Surgery After Augmentation, Lift, andReduction
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Fig. 25.3 Inverted T mastopexy. Cephalic malposition of the IMF
385
Fig. 25.5 Immediate postoperative view shows correct position of the
implant related to IMF
Fig. 25.4 Unstable IMF with bottoming out of the implant and IMF
malposition
25.3.3 How toAvoid It
Correct implant choice is the best way to avoid this deformity. If we choose a large implant in a patient with short
N:IMF (nipple to Inframammary fold) distance, we will need
to articially lower the IMF, the larger the implant, the more
the fold has to be lowered. Usually, it is safe to lower the IMF
1–2cm, below this point the risk of caudal displacement is
high (Figs.25.5 and 25.6). If the IMF is kept intact and the
implant slides under Scarpa’s fascia we will see a double
bubble effect, if the IMF is damaged or destroyed, we will
see a bottoming out deformity. It is of basic importance to
match the base and the curvature of the breast and the
implant.
Fig. 25.6 One-month postoperative image shows caudal displacement
of the implant due to IMF disruption. Note the scar position inside
lower pole curvature
Lower pole expansion can be easily predicted according
to implant selection (Hammond 2014; Adams and McKee
2016).
The catalogues of well know prosthesis brands’ mention the lower pole curvature length to predict the nal size
and expansion of the NAC-IMF distance. In addition, a
corrective factor must be added according to thickness of
tissues. For example, thin skins will require to add 1cm to
the nal length of the lower pole. Therefore, an implant of
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M. Romeo and G. Blugerman
7cm of lower pole curvature plus 1cm will require a lower
pole measurement in preoperative drawing of 8cm; otherwise, the implant will displace cranially being an undesired after effect. Thicker glandular tissue will require a
2cm correction factor, more than 2cm might put at risk
the nal breast geometry with unbalance between lower
and upper pole.
Moreover, skin measures before surgery and at the end of
surgery can differ due to elastic retraction which can lead to
false values of the lower pole length.
To avoid mismeasurement, one should check the NACIMF distance before closure applying moderate tension to
the skin of the lower pole to simulate skin expansion once
the implant is placed.
Avoid subglandular plane especially in post-weight loss
people or with stretchmarks due to the poor resistance and
support offered by soft tissues, submuscular plane offers a
safer support.
25.3.4 How toTreat It
1. IMF incision is made. Implant capsule is opened.
2. Lower pole capsulectomy and upper pole capsulotomy
help cephalic displacement of the implant.
3. We usually change the plane of the implant to submuscu-
lar, if possible.
4. If a bigger implant is asked by the patient, avoid a wider
one, rather choose a more projected one.
1. We calculate the new IMF position with the patient in
standing position.
2. IMF incision is made with inverted “T” pattern. Implant
capsule is opened.
3. IMF is xed (Figs.25.9, 25.10, 25.11, and 25.12) (Video
25.2). A layer of 2/0 Vicryl® is applied to the Scarpa’s
Fascia and down to the costal layer, the stich must not be
Fig. 25.8 Left breast IMF reconstructed. It is possible to see higher
and more projected breast
Inferior capsulorrhaphy is performed according to preop-
erative marking (Figs.25.7 and 25.8).
25.3.5 How toCorrect IMF inMastopexy
Both in primary or secondary mastopexy, IMF xation is
paramount to either prevent or correct malposition.
Fig. 25.7 Preoperative marking for IMF reconstruction
Fig. 25.9 IMF is identied and lifted. A temporary implant is used as
sizer to better predict the nal shape
Fig. 25.10 A 2/0 Vicryl suture is stitched straight to the periosteal
plane. 2/0 PDS can be used; care must be taken as PDS lasts more than
Vicryl and can cause a permanent indent and IMF retraction
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387
The latter problem can be easily solved with a Skate ap
to re-build the nipple prominence.
Areola correction is a more complex problem due to the
risk of recurrence.
Hammond’s interlocking suture (Hammond etal. 2007)
proved to be an effective method to reduce incidence but is
not 100% successful and Goretex
®
sutures may not be avail-
able in every country.
25.4.1 How toTreat It
Fig. 25.11 The suture is secured to the Scarpa’s fascia to provide sup-
port and avoid hypercorrection
Fig. 25.12 Close the knots while visually controlling the skin retraction. Minor indent is allowed and will resolve spontaneously
too tight to avoid invagination of the skin. A 2/0 PDS is
recommended in case of tension to provide prolonged
support during the healing process.
25.3.6 Pearl ofWisdom
It is the author’s opinion that a change of mental approach
must be taken to avoid recurrence.
Commonly, surgeons treat diastasis of the NAC by trimming the excessive areola and closure by a round block support suture but these steps lead to high tension over the NAC
and risk of recurrence (Fig.25.13).
Our alternative involves total preservation of areolar
skin, which is collapsed over itself by a round block technique (Fig.25.14). With such procedure there is reduced
NAC tension and is more effective in preventing recurrence. During early recovery the NAC will be wrinkled
and unpleasant; later, the skin will smooth without
diastasis.
If the capsule is opened, it is possible to temporarily remove
the implant and leave it completely soaked in a saline solution with antibiotics; the implant can then be repositioned
with the same caution of a brand-new implant without relevant risks. Always have a spare implant during surgery.
25.4 NAC Malposition
Nipple-areolar complex malposition is a common deformity
that can either be primary or secondary during mastopexy or
periareolar mammaplasty.
Malposition can be related to diastasis of the areola,
including nipple atrophy due to the centrifugal tension
forces.
Fig. 25.13 Common approach for NAC malposition or diastasis
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M. Romeo and G. Blugerman
Fig. 25.16 Preoperative drawing
Fig. 25.14 Centripetal contraction of the NAC without trimming; a
round block suture is performed around it
Fig. 25.15 Left breast ptosis, medial pole rippling and areolar
diastasis
Fig. 25.17 Three months postoperative evolution; the cleavage is corrected, areolas are symmetric, right breast tuberosity is corrected too
Figures 25.15, 25.16, 25.17, 25.18, 25.19 and 25.20 show
two clinical cases with this approach, with and without nipple reconstruction.
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Fig. 25.18 NAC diastasis with nipples atrophy
389
25.5 High Riding NAC Malposition
One of the most difcult (to solve) and dreaded complications of breast surgery is the “high riding” malposition of the
NAC.
The nipple-areola complex should always be placed at the
equatorial line of the breast when observed from the lateral
view, oriented at zero degrees or slightly pointing upward
(up to +5°) (Fig.25.21); if the NAC is higher than that, we
are facing a malposition of NAC (MNAC) (Fig.25.22). A
Fig. 25.19 Preoperative drawing with Skate aps and top limit of the
new NAC position
Fig. 25.20 Two months post-op image. Wrinkling is setting down;
nipples are stable and projected
Fig. 25.21 Correctly orientated NAC after breast augmentation. The
areola is centered in the breast mound and the nipple is slightly oriented
upward (dotted blue line)
Fig. 25.22 High riding NAC; the areola complex is completely placed
in the upper pole
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M. Romeo and G. Blugerman
slight but signicant difference exists between MNAC and
pseudo-malposition; the latter happens when the NAC is correctly placed but the gland and/or the implant is wrongly
placed (see Fig.25.6) with excessive length of the lower pole
that alters the volume distribution of the breast, leaving the
upper pole empty and the NAC free to rotate upward.
25.5.1 Evaluation andCauses ofMalposition
Understanding the cause and timing of MNAC is crucial to
correct it properly. After breast cancer treatments, radiotherapy, nipple sparing mastectomy, or ap reconstruction there
may be cranial displacement of the NAC.In esthetic surgery,
most of the times the cause depends on overcorrection of
NAC-pexy with incorrect preoperative planning.
25.5.2 Correction
In case of pseudo-MNAC or a moderate real MNAC we can
readjust the relationship between the NAC and the breast
mound by lifting the latter. A secondary mastopexy can displace cranially the gland/implant allowing caudal rotation of
the NAC. This method can be used if the breast volume is
lifted up to the third rib to solve the problem; higher lifting
would produce an unnatural high riding breast and should
not be performed.
The second option is to rotate downward the NAC pedicle
or graft it. Unfortunately, both options leave a scar visible in
the upper chest as unpleasant and permanent sequalae.
25.5.3 Pearls ofWisdom
Regardless whether it is a primary or secondary surgery,
NAC vascular abnormality can be immediate or can be visible during the rst hours. Release of stitches and/or use of
local vasodilator, such as nitrogen oxide/nitroglycerine
patches, are common options to improve vascularity, but
severe venous congestion or ischemia can be detected late
with irreversible compromise of the NAC.
25.6.1 How toTreat It
Either as an intraoperative complication or an expected scenario (a secondary case, for example), NAC skin grafting can
be a safe, predictable, and esthetically satisfactory solution.
A dermal ap can be raised easily during breast reduction/mastopexy and grafted. A 4/0 running Vicryl Rapide®
suture can secure the graft and leave no relevant marks
around the areola. Compressive dressing with ointment
should be left in place like any other skin graft.
25.6.2 Pearl ofWisdom
Timing is very important to determine outcome. The best
result is achieved by a swift decision at surgery table.
Nevertheless, skin graft can be still performed during the following hours (up to 6 h according to our experience).
Unfortunately, delay leads to tissue ischemia and worse scarring (Fig. 25.23). Figures 25.24, 25.25, and 25.26 show
immediate right NAC graft due to intraoperative ischemia.
It is our opinion that it still worthy to perform grafting to
prevent a long and psychologically difcult delayed NAC
reconstruction.
Correct NAC placement is a concern especially for young
surgeons. In case of doubt, 1 or 2cm of under correction will
be acceptable, raise the NAC secondarily, even under local
anesthesia, is easy and safe and we protect both the surgeon
and the patient from a permanent esthetic damage.
25.6 Nipple-Areolar Complex (NAC)
Necrosis
NAC necrosis is not a primary deformity itself but the resultant scarring certainly is. Plus, the postoperative care and
reconstruction are a frustrating process for both the surgeon
and the patient.
Fig. 25.23 Delayed NAC grafting. The right areolar complex was
grafted 6h after surgery due to venous congestion. The discolored nipple was a consequence of the delayed process. Secondary direct closure
resolves it or a tattoo can correct the problem
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