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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_654_Библиотеки_им_академика_М_И_Перельмана
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25 Corrective Breast Surgery After Augmentation, Lift, andReduction
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Fig. 25.24 Implant removal and Ribeiro mastopexy. As a secondary
procedure the risk of ischemic necrosis of the NAC was high
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25.7 Dynamic Breast Deformity (Implant
Animation)
Implant animation is dened by the interaction of the muscular system (mostly the pectoralis major), the implant and its
capsule in a submuscular or dual-plane breast augmentation,
which causes unesthetic displacement of the implant during
muscular voluntary contraction, possibly related to pain and
even rippling.
Most of the time, animation is caused by wrong operative
planning/execution when the muscle is not completely cut in
the lower medial quadrant to allow free displacement of the
implant during muscle contraction. Also, high textured
implants are known to adhere severely to the capsule, which
is tightly related to the muscle, therefore causing implant
animation even when surgery is correctly performed.
25.7.1 How toPrevent It
Avoid using high textured implants to prevent “Velcro effect”
is a relevant step. Inferior medial quadrant muscle detachment at 90° is mandatory, a 2cm perpendicular split is also
useful, especially in powerful pectoralis major patients.
Fig. 25.25 Seven days post-op, right nipple was grafted due to secondary ischemia. NAC graft survived 100%
Fig. 25.26 9months post-op aspect. The esthetic outcome is acceptable for the patient
25.7.2 How toCorrect
Implant and capsule condition must be evaluated. In case of
broken implant and/or capsule contracture, calcication, and
adherence to the implant, complete capsulectomy should be
performed in an “en-bloc” fashion (Fig.25.27); in all other
scenarios, the capsule can be preserved, performing only
partial capsulectomy of the inferior medial quadrant (IMQ).
Fig. 25.27 En-bloc capsulectomy. The capsule is completely removed
as a sealed pocket with the implant inside. This capsule has a grade IV
contracture and a beginning of a calcication process
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Complete muscle incision in the IMQ is mandatory
according to preoperatory evaluation.
25.8 Rippling
When a woman’s soft tissues are too thin to hide a prosthesis,
rippling may occur.
Retroglandular implantation, thin patient, oversized
implants, capsular contracture, and muscle animation are
among the causes of a visible or just palpable implant, quite
often the patient will ask a secondary procedure to improve it.
25.8.1 How toCorrect
Using a harder and more-lled implant can be an intuitive
way to reduce visible ripples but can stress the skin with
more tension and cause recurrence. The best way to solve the
problem is to increase the thickness of soft tissues to hide the
implant.
Preserving the capsule, if possible, is strategic. The posterior portion of the capsule can be cut and turned as a ap to
the medial pole to double the layers around the implant
(Video 25.3); moreover, the space between the skin and the
capsule itself is an ideal sealed environment to perform lipolling (Fig.25.28).
Retromuscular plane is mandatory to provide as much
coverage as possible, only round implants are used to avoid
rotation issues.
M. Romeo and G. Blugerman
Fig. 25.29 Dynamic retraction of the breast, leading to lateral malposition, pain, and rippling
Clinical Case
Figures 25.29, 25.30, 25.31, and 25.32 show the before and
after of rippling and muscle animation correction. Dynamic
view can be seen in Video 25.4.
Fig. 25.28 Vascularized fat grafting between the capsule and the skin;
this space is ideal for fat survival
Fig. 25.30 Oblique view of the dynamic retraction. Rippling and lateral displacemente are visible
25.8.2 Pearls ofWisdom
Don’t forget to preserve the capsule laterally or to perform
capsulorrhaphy to prevent lateral displacement after complete capsule removal, it is easy to focus on the medial pole
and neglect the lateral boundary of the pocket.
25 Corrective Breast Surgery After Augmentation, Lift, andReduction
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Fig. 25.31 9months postop-op, shape is stable, rippling is corrected,
medialization and cleavage denition are achieved
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25.9.1 How toPrevent It
During primary breast augmentation, it is important to
release pectoralis major in the lower medial quadrant to
avoid animation and allow the implant to better sit medially
and ll the cleavage.
At the same time, lateral dissection must be rather
conservative.
A blunt dissection going just lateral (1 or 2 cm) to the
nipple vertical line is sufcient in most of the cases to maintain a good lateral support due to the fact that the implant
achieves a “self-dissection” of the lateral pole during post-op
period.
25.9.2 How toCorrect It
In case of secondary lateral displacement with submuscular pocket, lateral capsulectomy/capsulorrhaphy can solve
the deformity with/without medial capsulotomy (Video
25.5).
If pectoralis muscle is intact, an intramuscular approach
can be performed leaving a 2cm wide lateral sling that supports the implant as a hammock preventing lateral malposition (Ono and Karner 2019) (Fig.25.33).
Fig. 25.32 Upper pole is lled with a harmonic prole
25.9 Lateral Implant Displacement
Lateral implant displacement is a relatively frequent deformity mostly related to wrong preoperative planning or
execution.
Fig. 25.33 Muscle sling to support the implant laterally
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M. Romeo and G. Blugerman
25.9.3 Pearls ofWisdom
Sometimes, when medial pole is left empty, one can think of
a wider implant to ll the cleavage. It is a common mistake
that can lead to lateral overll; pocket shape control is the key
to obtain a successful result, not a bigger or broader implant.
25.10 Expectations andLegal Aspects
Revision surgery is a tough task for anyone, there are technical, emotional, and legal aspects to be taken into account.
This chapter has explained so far how to deal with technical issues, but a patient with frustrations due to his unrealistic expectations is unpredictable and can either blame the
rst or the last surgeon for his/her dissatisfaction; besides,
whoever does the last surgery removes the traces of previous
ones and carries the burden of the whole process. Thorough
explanation of the surgery, risks and margin of improvement
must be explained in the sincerest way. The reconstructive
aspect of the procedure must be stressed over the mere
esthetic purpose. Specic consent forms for revision surgery
should be provided and signed.
25.11 Final Considerations
Although all of us, surgeons would want a single lifetime
stable surgery for each patient, reality is far from it. As the
body changes through the decades, revision surgery is an
inevitable event. Secondary surgery, either of our or others’
patients, is a scenario that any breast surgeon must be able to
deal with. If we embrace the challenge, we will face defying
cases which can be highly satisfying both for the surgeon and
the patient.
One should remain humble, resist from judging other’s
cases; failure is around the corner for every surgery.
Last, but not in the least, one should refrain from going far
beyond one’s own experience; despite our good intentions,
we must balance the risks and benets and bow out from
surgery if improvement is not in our grasp and within our
skill set.
References
Adams WP, McKee D.Matching the implant to the breast: a systematic
review of implant size selection systems for breast augmentation.
Plast Reconstr Surg. 2016;138(5):987–94.
Adams WP, etal. Macrotextured breast implants with dened steps to
minimize bacterial contamination around the device: experience in
42,000 implants. Plast Reconstr Surg. 2017;140(3):427.
Hammond DC. Technique and results using MemoryShape implants
in aesthetic and reconstructive breast surgery. Plast Reconstr Surg.
2014;134(3 Suppl):16–26.
Hammond D, Khuthaila D, Kim J.The interlocking Gore-Tex suture
for control of areolar diameter and shape. Plast Reconstr Surg.
2007;119:804–9.
Headon H, Kasem A, Mokbel K.Capsular contracture after breast aug-
mentation: an update for clinical practice, vol. 42; 2015. p.532.
Ono MT, Karner BM.Four-step augmentation mastopexy: lift and aug-
mentation at single time (LAST). Plast Reconstr Surg Glob Open.
2019;7(11)
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