Capsular Flap for Correction of Contour Deformities of the Breast

Transaxillary Capsulorrhaphy with Reimplantation to Correct Bottoming-Out Deformity in Breast Mycobacterial Periprosthetic Infection: A Case Report with Literature Review

Augmentation mammoplasty is one of the most popular cosmetic surgeries, but there is a high reoperation rate (29.7%) commonly due to capsular contracture, implant malpositioning, infection, and unsatisfactory size. Although infection only accounts for 2% of cases, its management is very challenging, especially with nontuberculous mycobacteria (NTM) infection. Breast prosthetic NTM infection is a rare but is a disastrous condition with an incidence of approximately 0.013%. Immediate salvage reimplantation is usually not suggested, and most studies recommend a gap of 3 to 6 months after combination antibiotics therapy before reimplantation. However, delayed reimplantation often leads to great psychological stress and struggle between the doctor and patient. We present the case report of successful reimplantation in treating prosthetic NTM infections in a 28-year-old female. We discuss a novel technique "transaxillary capsulorrhaphy" to correct the bottoming-out deformity. One year after the combination of antibiotics and surgery, the follow-up computed tomography scan showed complete remission of NTM without recurrence. We discuss the surgical technique in detail. The 1-year follow-up assessment (photos and dynamic video) revealed good cosmesis and reliable correction using the new technique. This report is the first formal description and discussion of one-stage reimplantation following NTM infections. Transaxillary capsulorrhaphy allows for a successful salvage operation when an implant is displaced. This approach provides highly favorable result in eastern women undergoing revision augmentation mammoplasty. This study reflects level of evidence V, considering opinions of respected authorities based on clinical experience, descriptive studies, or reports of expert committees.

Mastopexy on Reconstructed Breast Following Massive Weight Loss: An Innovative Technique Using Dermo-Capsular Flaps

BACKGROUND

We have developed a dermo-capsular flap mastopexy technique for patients who have experienced massive weight loss after breast reconstruction. The aim of this technique is to lift the inframammary fold, adequately cover the implant, and remove excess skin, elevating the breast and obtaining symmetry with the contralateral breast.

METHODS

Between January 2014 and February 2017, we performed this technique on 20 women who were candidates for second-stage breast reconstruction following nipple-sparing mastectomy. All patients had experienced substantial weight loss (> 15 kg) and presented with ptosis after first-stage reconstruction.

RESULTS

There were 8 patients with bilateral reconstruction following bilateral mastectomy (4 with bilateral nipple-sparing mastectomy). There were 12 patients with unilateral mastectomy, all with contralateral breast ptosis treated by augmentation via inverted-T mastopexy (n = 7) or crescent mastopexy (n = 5). The average lift of the nipple-areola complex was 5 cm (range 2-8 cm). The average follow-up was 12 months (range 4-36 months). Two patients had complications, including partial wound dehiscence (in a heavy smoker) and recurrence of breast asymmetry.

CONCLUSIONS

Implant breast reconstruction after massive weight loss is still possible even in the setting of thin, ptotic, and anelastic breast tissue. Our inverted-T dermo-capsular flap mastopexy technique for reconstructed breast is safe and effective with good outcomes and high patient satisfaction.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Autologous Collagen Matrix (ACM): Lower Pole Support With a Supero-Anterior Capsular Flap in Secondary Subpectoral Breast Augmentation

Background

Secondary aesthetic breast surgery is a complex and challenging scenario. It requires the surgeon to identify contributing factors, provide patient education, make a further management plan, and optimize the conditions for a favorable result. Various techniques have been described in literature but the rate of reoperation is still high. The first author has been using a supero-anterior capsular flap with a neopectoral subcapsular pocket and an implant change in these cases.

Objectives

To review the patient characteristics, indications, and early results of using part of the existing implant capsule for secondary subpectoral breast augmentations.

Methods

All patients who underwent secondary breast augmentation, over a period of 2 years by the first author (P.M.), using the supero-anterior capsular flap technique were included. The technique involves dissection of a new subpectoral pocket and uses the existing implant capsule as an internal brassiere.

Results

A total of 36 patients were operated by this technique. Of these, 17 patients had developed a complication while 19 patients wanted a change in size only. At a mean follow up of 10.2 months, there was no bottoming out, double bubble, or capsular contracture.

Conclusions

This reliable technique provides stable results as shown by low rate of complications with the existing follow up.

Level of Evidence 4

Techniques to refine the upper outer breast aesthetic subunit in alloplastic breast reconstruction: The lateral capsular flap

BACKGROUND

Lateral displacement of breast implants and axillary fullness are common causes of patient dissatisfaction and reoperation following prosthetic breast reconstruction. Suture plication of the capsule and acellular dermal matrix slings have been described to address lateral implant malposition, but with unacceptably high rates of recurrence and additional cost, respectively.

OBJECTIVE

To describe a novel technique using a lateral capsular flap to provide durable correction of implant malposition and, at the same time, redefinition of the lateral breast border, thereby restoring balance to the breast aesthetic subunits.

METHODS

Sixteen patients presented with lateral malposition of tissue expanders or breast implants during staged implant-based breast reconstruction, four of whom had additional unwanted axillary soft tissue fullness. An anteriorly based lateral capsular flap was performed for each breast to reconstruct the lateral border of the breast, return the implant to its appropriate position and address axillary fullness when indicated.

RESULTS

Lateral capsular flaps were performed for 16 patients (20 breasts) resulting in durable medial repositioning of the implant for a minimum of six months follow-up (range six to 60 months). Eight patients presented after implant placement with subsequent malposition while the remainder presented after tissue expander placement alone. For the eight patients with axillary fullness, elevation of the capsular flap allowed access to axillary contents for excision (four cases) or incorporation of axillary fat into the flap to prevent lateral implant palpability. No major complications, infectious complications or wound healing complications were reported. All patients showed satisfactory results, and reported high cosmetic and functional satisfaction with the appearance of their reconstructed breasts and axillary comfort.

CONCLUSIONS

In the authors' experience, the lateral capsular flap represents a simple, safe and reliable technique to correct breast implant lateral malposition, reconstruct the lateral breast border, and address unwanted axillary fullness in primary or revision implant-based breast reconstruction with improved cosmetic appearance and balance of the breast.

Techniques to refine the upper outer breast aesthetic subunit in alloplastic breast reconstruction: The lateral capsular flap

Background

Lateral displacement of breast implants and axillary fullness are common causes of patient dissatisfaction and reoperation following prosthetic breast reconstruction. Suture plication of the capsule and acellular dermal matrix slings have been described to address lateral implant malposition, but with unacceptably high rates of recurrence and additional cost, respectively.

Objective

To describe a novel technique using a lateral capsular flap to provide durable correction of implant malposition and, at the same time, redefinition of the lateral breast border, thereby restoring balance to the breast aesthetic subunits.

Methods

Sixteen patients presented with lateral malposition of tissue expanders or breast implants during staged implant-based breast reconstruction, four of whom had additional unwanted axillary soft tissue fullness. An anteriorly based lateral capsular flap was performed for each breast to reconstruct the lateral border of the breast, return the implant to its appropriate position and address axillary fullness when indicated.

Results

Lateral capsular flaps were performed for 16 patients (20 breasts) resulting in durable medial repositioning of the implant for a minimum of six months follow-up (range six to 60 months). Eight patients presented after implant placement with subsequent malposition while the remainder presented after tissue expander placement alone. For the eight patients with axillary fullness, elevation of the capsular flap allowed access to axillary contents for excision (four cases) or incorporation of axillary fat into the flap to prevent lateral implant palpability. No major complications, infectious complications or wound healing complications were reported. All patients showed satisfactory results, and reported high cosmetic and functional satisfaction with the appearance of their reconstructed breasts and axillary comfort.

Conclusions

In the authors' experience, the lateral capsular flap represents a simple, safe and reliable technique to correct breast implant lateral malposition, reconstruct the lateral breast border, and address unwanted axillary fullness in primary or revision implant-based breast reconstruction with improved cosmetic appearance and balance of the breast.

Breast implant capsule flaps and grafts: a review of the literature

BACKGROUND

A breast implant capsule forms as a physiological response to the foreign material. Over the past decades, authors started to consider the breast implant capsule as a new source of tissue, thus describing several capsular flaps and grafts. The aim of this article is to provide an overview of the applications and indications for the use of capsular tissue flaps and grafts in reconstructive and aesthetic surgery.

METHODS

A review of the literature on breast implant capsule grafts and flaps was conducted. The reported surgical techniques were described and compared for indications and complications. The studies were evaluated and compared for number of patients and follow-up.

RESULTS

The search yielded a total of 21 citations. Patient population was reported in 11 studies for capsular flaps and 2 articles for capsular grafts. Between 1997 and 2012, a total of 74 patients underwent surgery with the use of capsular tissue. Among these, 60 patients had a capsular flap (81 %) and 14 (19 %) had a capsular graft. Complications were experienced in 5 patients (6.7 %).

CONCLUSIONS

Capsular flaps and grafts are indicated mainly to address breast implant-related problems. The breast implant capsule represents a versatile and reliable source of tissue for both aesthetic and reconstructive surgery.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266.

The capsular hammock flap for correction of breast implant ptosis

A well-defined inframammary fold (IMF) is essential in providing an aesthetically pleasing and stable result in breast procedures. The position of the IMF on the chest wall determines the "footprint" of the breast, and hence the breast and chest aesthetic as a whole. Implant malposition is reported in the literature to occur in 5-8 % of primary breast augmentation patients. This occurs most commonly in a caudal direction, which is the most difficult problem to correct, as reported by Tebbett (Clin Plast Surg 28:425-434, 2001). Numerous surgical techniques to correct the malpositioned IMF have been described, including periosteal anchorage techniques as reported by Persichetti et al. (Ann Plast Surg 70:636-638, 2013), periareolar approaches that secure the IMF to the rib cage, and superiorly based capsular flaps. Here we describe a novel simple capsular flap technique using the lower anterior capsule, which is divided and formed into an inferiorly based flap and used as a "hammock" to re-establish the IMF and support the implant. As the capsule is made of a compact fibrous shell with a dense collagen network and excellent blood supply, using it as a flap to reposition and maintain the implant is ideal. Previous studies and tests have shown the reliability of capsule-based flap reconstruction due to the capsule's intrinsic strength and good vascularity, as shown by Rubino et al. (Ann Plast Surg 46:95-102, 2001). We describe our series of 12 primary breast augmentation patients with caudal implant malposition who underwent IMF reconstruction and implant repositioning with this technique. We explain our simple and repeatable technique that shows a stable and very durable result in repositioning the IMF and implant, with no recurrence of implant ptosis.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Capsular grafts and flaps in immediate prosthetic breast reconstruction

BACKGROUND

Patients with previously augmented breasts and a diagnosis of breast cancer who are candidates for immediate prosthetic reconstruction can benefit from capsular tissues used for splinting the position of the pectoralis major muscle.

METHODS

A retrospective clinical review of patients with previously augmented breasts who are undergoing mastectomy and immediate prosthetic reconstruction with capsular tissues was undertaken. The bottom of the periprosthetic capsule was tailored in a novel and versatile fashion as grafts or flaps and used as a sling between the pectoralis major and the inframammary fold.

RESULTS

Of the 21 patients in this study, 19 had unilateral reconstruction, whereas 2 had bilateral reconstructions. Capsular tissues were harvested as free capsular grafts in 15 cases and raised as a capsular flap in the remaining 8 cases. During the follow-up period, complications were detected in 7 patients (1 seroma, 1 infection, 1 hematoma, 1 superficial epidermolysis, 2 cases of rippling, and 1 mild capsular contracture).

CONCLUSIONS

For eligible patients, the use of capsular tissues offers a readily available and cost-effective alternative to acellular dermal matrices with a negligible complication rate. Patient selection is key to ensuring a safe oncologic approach and must be carefully carried out in close collaboration with the breast surgeon.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Capsular flap: new applications

Breast augmentation with silicone implants is one of the most commonly performed procedures for women seeking improvement in their body image. Because the number of breast augmentation operations is growing, the number of subsequent reoperations is increasing. Causes for repeated operative procedures include infection, capsular contracture, silicone implant replacement, and breast reaugmentation. As the average volume of silicone implants used is steadily growing according to patients' wishes and fashion requirements, the plastic surgeon often is asked to replace the silicone implants with larger implants. Replacing breast implants with a similar sized implant is a relatively simple operation, but insertion of larger implants may present a challenge due to insufficient soft tissue coverage of the lower pole of the larger breast implant, especially in thin subjects. Total coverage of the breast implant can be achieved by use of tissue substitutes (TS), such as acellular dermal matrices. Usage of TS, however, is prone to complications and very costly, and these factors influence the implementation of TS in a private practice setup. This report describes a capsular flap used to cover the lower pole of breast implants. The flap guarantees multilayered stable wound closure and prevents displacement of the inframammary fold. The capsular flap also was used to correct an inferiorly displaced inframammary fold as a consequence of the breast augmentation.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Capsular flaps for the management of malpositioned implants after augmentation mammoplasty

Among the reasons for reoperation after augmentation mammaplasty is the malpositioned implant, especially a lowered inframammary fold or symmastia, which is difficult to repair. The peri-implant capsule, a physiologic response to a foreign body, is naturally formed and suitable for use as a flap because of its high vascularity. In addition, it is sufficiently tough for suspension of the implant. The authors introduce the idea that the capsular flap is very useful for the correction of symmastia or a lowered inframammary fold. In such situations, the capsular flaps are used to prevent migration of the implant after raising of the inframammary fold or defining of the midline with capsulorrhaphy. This technique successfully corrected the malpositioned implants in this study, and all the patients were satisfied. There was no recurrence of a lowered inframammary fold or symmastia. These findings suggest that the capsular flap should be considered a safe and effective option for the management of malpositioned implants.