The “Neosubpectoral” Pocket for the Correction of Symmastia:

A case of extracapsular silicone gel implant rupture with contralateral gel migration

Symmastia is a rare complication of augmentation mammaplasty that occurs when a breast implant crosses the midline and connects with the contralateral implant pocket. We present a case of implant rupture, migration to the contralateral breast, and ultimate symmastia following a traumatic fall in a patient with prior breast augmentation.

Congenital and Acquired Symmastia: Experience from 100 Cases Treated

BACKGROUND

Symmastia, first defined by Spence et al. in 1984, is a medical condition characterized by the convergence of breast tissues in the midline, resulting in the absence of adhesion between the skin and subcutaneous tissue over the presternal area. It can be either congenital or acquired. Currently, there is no universally accepted treatment for symmastia. This study presents a surgical approach and preoperative and postoperative care for the correction of symmastia.

METHODS

Between January of 2014 and December of 2020, a surgical technique was performed on 100 patients, including 59 with congenital symmastia and 41 with acquired symmastia. The technique involved creating a thin skin flap and attaching it to the sternum to reconstruct the intermammary V-shaped region.

RESULTS

All patients in both groups underwent subglandular implant placement, with textured/polyurethane prostheses used in 97% of cases. Three cases did not use any implants. In the corrective surgery, patients received smaller, round implants, following the steps of the surgical approach devised by the author. The median satisfaction scores were high in both groups.

CONCLUSIONS

The surgical approach described in this study is a safe, one-time procedure with a low risk of complications and high patient satisfaction. The technique is reproducible and provides consistent outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Acquired Symmastia: Classification, Causes, and Repair Strategy

BACKGROUND

Acquired symmastia is a rare complication after breast augmentation that is difficult to fix.

METHODS

The medical records of 18 female patients with symmastia treated by our team were reviewed. Data collected included preoperative medical history, implant size, and breast base width. Surgical techniques were systematically reviewed and analyzed based on postoperative follow-up results.

RESULTS

Of the 18 patients, 15 patients had undergone implanted breast augmentation and 3 had injected breast augmentation. All 18 patients underwent comprehensive repair with various surgical techniques. Three patients showed recurrence after operation. Four patients were dissatisfied with postoperative breast size and underwent 2-stage replacement surgery.

CONCLUSIONS

Symmastia is an intractable surgical complication. Surgical classification can help assess the difficulty of surgery in advance, and the surgical strategy plan can help the surgeon to control the quality of the repair surgery.

Reoperative Augmentation Mammoplasty: An Algorithm to Optimize Soft-Tissue Support, Pocket Control, and Smooth Implant Stability with Composite Reverse Inferior Muscle Sling (CRIMS) and its Technical Variations

BACKGROUND

Reoperative augmentation mammoplasty (RAM) is a challenging procedure, with the highest rates of complications and revision. Complications include implant malposition, lateral displacement, bottoming out, and rotation. These deformities can be addressed with various procedures, but the pocket control and stability of the new smooth implant surface may present limitations.

OBJECTIVES

This study revisits a previously described predictable approach in primary breast augmentation and defines a surgical treatment algorithm for RAM technique selection.

METHODS

Between 2017 and 2021, 72 patients (144 breasts) underwent RAM with composite reverse inferior muscle sling (CRIMS) technique and its technical variations (types I-IV). CRIMS technique involves placing a silicone gel implant into the submuscular (SM) pocket with an inferior sling of the pectoralis major muscle based on the dimensions of the implant, in combination with support points/dermal bridge sutures to stabilize the implant and glandular tissue at the lower breast pole (LBP). Reasons for surgery were ptosis (92%), implant and malposition (59.6%). Patients were followed for at least 6 months in 5 cases (6.9%), at least 12 months in 50 cases (69.4%), for at least 36 months in 10 cases (13.8%), and more than 36 months in 7 cases (9.7%) (mean 34 months; range 6-48 months). Patients were evaluated in terms of resolution of symptoms, satisfaction, and complications. Three-dimensional imaging (3DI) obtained from the Divina scanner system was used and followed up for 1 year to evaluate breast position, lower pole stretch (LPS), and intermammary distance (IMD).

RESULTS

Eleven cases of minor complications were observed in 9 patients (12.5%): hypertrophic scarring in 4 (5.5%), wound dehiscence in 4 (5.5%), Baker II/III capsular contracture in 1 (1.3%). SmoothSilk surface silicone implants were used in all cases, with an average volume decrease of 120 cc. Sixty-eight patients (94.4%) were either very satisfied/satisfied with their aesthetic result. Breast images were performed in a group of 65 patients (90.2%), and in 7 breasts (10.7%), localized oil cysts were observed. The value for LPS was 7.87% (p <0.0001) between 10 days and 1 year, with the majority occurring early in the first 3 months, indicating that the LBP/implant remains steady during the last months of follow-up. No cases of fat necrosis/seroma were observed. There were no signs of intra/extracapsular ruptures, capsular contracture. There were 2 cases (3%) of minimal implant displacement and no cases of rotation.

CONCLUSIONS

CRIMS and its variations can be performed successfully in RAM. An algorithmic approach can facilitate the pre- and intraoperative decision-making process and provide the new pocket control and implant stability with acceptable complication rates. Further accurate evaluation is recommended to understand the benefits or disadvantages of CRIMS compared to other RAM techniques.

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 .

Revision Breast Augmentation

Breast augmentation is consistently one of the most commonly performed aesthetic operations every year. Unfortunately, revision rates following primary augmentation remain as high as 36%. There are several causes for revision breast augmentation; however, the most common and challenging of these include capsular contracture, implant malposition, and ptosis of the aging breast following augmentation. Successful management of these problems requires knowledge on how to best treat the implant and capsule with the corresponding soft tissue simultaneously. While surgical management is important, understanding the pathological causes of these entities during the primary operation can reduce the need for revision. This article utilizes the most up-to-date literature to review the appropriate clinical evaluation and surgical management of these complex cases.

Revisional Breast Surgery: Are Surgical Plans Changed if the Patient Has a Textured Device?

SUMMARY

The authors reviewed the available evidence on revision surgery following implant-based breast surgery with the aim of investigating whether any difference in the surgical approach should be proposed if the patient has a textured device. They included in their review 31 studies presenting different approaches for revision surgery following implant-based breast surgery (both aesthetic and reconstructive), with a level of evidence ranging from 4 to 5. None of the included studies proposed different surgical approaches for revision surgery in patients carrying textured devices. The authors conclude that no different surgical attitudes in revision surgery following implant-based breast surgery should be adopted if the patient has a textured device according to the available evidence, when a correct approach is performed to face the complication or adverse event, following a thorough preoperative study of the patient with the proper diagnostic tools.

Correction of Suboptimal Results in Implant-Based Breast Reconstruction

Implant-based breast reconstruction is the most common means to rebuild the breast following mastectomy. Although largely successful in restoring breast shape, suboptimal results may occur secondary to inadequate size or projection, malposition, rippling and contour irregularities, nipple malposition, capsular contracture, or implant rotation/flipping. This article reviews common strategies to improve implant reconstruction outcomes with revisional surgery.

LEVEL OF EVIDENCE: 4

Surgical treatment of symmastia: A systematic review of techniques, outcomes and complications

BACKGROUND

The term "symmastia" defines a confluence across the mid-sternal line of the breast mounds and subsequent loss of adhesion between sternum and pre-sternal skin. This condition can be congenital or, more frequently, iatrogenic. Despite the number of different treatments published in literature, no systematic review or surgical techniques classification has been attempted in literature. There is, therefore, a concrete need to elucidate surgical options and propose a treatment algorithm, improving surgical practice and patient's care.

OBJECTIVE

This systematic review aims to collect and evaluate the published evidence on surgical procedures to correct symmastia deformities (both congenital and acquired) in order to clearly overview possible treatments and outcomes related to this surgery, providing a surgical classification guide as well.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, PubMed database was queried for papers describing symmastia surgical treatment, along with operative indications, outcomes, and complications.

RESULTS

In this review, 23 articles and 118 patients were finally included. Four main categories of treatment were identified: dermo-sternal adhesions, capsulorrhaphy, neopocket creation, and muscle repair. Symmastia correction was achieved and satisfactory in 108 of patients, despite varying techniques. Globally, recurrence was the most frequent complication, reported in the 8.5% of cases.

CONCLUSION

Symmastia represent a difficult condition to treat and recurrence is a common problem. Because of the low number of patients involved in the studies, it is difficult to make conclusions as to the superiority of one technique over another. However, this review, collecting comprehensively for the first time the surgical knowledge over this topic, could guide the surgeon to choose the best surgical treatment based on nowadays evidence.

Iatrogenic Symmastia: Causes and Suggested Repair Technique

BACKGROUND

Various theories exist to explain the etiology of iatrogenic symmastia. Subglandular over-dissection of the medial breast pocket over the sternum, disruption of midline sternal fascia, oversized implant base diameter, and over-dissection of the medial pectoralis muscle attachments to the sternum are popular explanations.

OBJECTIVES

The authors hypothesized that the most common risk factor for iatrogenic symmastia is subpectoral breast augmentation.

METHODS

A retrospective chart review was conducted including all symmastia patients who underwent surgery from January 2008 to April 2018 by a single surgeon (C.L.M.). ASAPS members were also surveyed regarding the etiology and incidence of symmastia in their practice.

RESULTS

Twenty-three patients with symmastia were included in the retrospective chart review. All had previous subpectoral breast augmentation. In the ASAPS survey, 91 plastic surgeons reported seeing an average of 2.2 consults for acquired symmastia over the preceding year; 1.9 of the 2.2 (84.9%) acquired symmastia consults previously underwent subpectoral breast augmentation. Most surgeons attributed these patients' symmastia to over-dissection of the medial pectoralis muscle attachments to the sternum.

CONCLUSIONS

Symmastia is most often caused by pectoralis major sternal dehiscence during subpectoral breast augmentation. In the senior author's experience, all patients with iatrogenic symmastia previously had a submuscular breast augmentation. The ASAPS survey supports multiple causes for symmastia with retromuscular breast augmentation occurring in the majority of patients. Repair of symmastia should include securing Scarpa's fascia to the sternum, reattaching the pectoralis major to the sternum, avoiding another subpectoral implant, and using postoperative modalities to protect the repair.

LEVEL OF EVIDENCE: 4

An efficient method for the correction of iatrogenic symmastia: A case series

Background

Symmastia is a medial confluence of the breasts, produced by a web of skin and fat merged across the midline, that generates the disappearance of the intermammary sulcus. Apart from the rare congenital cases, this condition is usually a result of technical complications during breast augmentation surgery.

This article describes a simple and reliable method for correcting symmastia.

Methods

From November 2006 to June 2015, we treated 10 patients with acquired symmastia who had previously undergone an implant-based reconstruction. We performed a crescent-shape medial capsulectomy and we then performed an adequate and resistant closure with a substitute device, consisting of a Tuohy epidural needle and polydioxanone sutures, which are easily accessible and inexpensive. The process outcome was successful and resulted in a normal cleavage between the breasts.

Results

Mean follow-up was 24 months. We haven't observed any recurrence of symmastia to date in this study. One postoperative hematoma and one seroma occurred. All ten patients achieved acceptable results through the procedure.

Conclusion

Our pericapsular Tuohy technique for medial closure of the pocket is a practical and efficient substitute to traditional capsulorraphy and provides reliable and reproducible results.

•

An easy way for perform a medial capsulorraphy.

•

It provides reliable and reproducible results.

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Useful when it's not possible to perform classical capsulorraphy.

Contralateral Augmentation with a Transmidline Scarless Technique During Unilateral Breast Reconstruction Using Implants

BACKGROUND

Unilateral breast reconstruction can be a challenge when attempting to achieve an aesthetically pleasing and symmetrical breast mound on the contralateral side. This study investigates the outcomes of using a contralateral augmentation transmidline scarless (CATS) technique to simultaneously augment the contralateral breast using implants.

METHODS

Between January 2004 and July 2016, patients undergoing unilateral implant-based breast reconstruction and simultaneous contralateral implant augmentation using a transmidline access were studied. Characteristics and complications using this technique were assessed.

RESULTS

Sixty-five (91.5%) of 71 patients used the CATS technique for unilateral breast reconstruction using implants with contralateral breast implant augmentation. The remaining 6 cases used a preexisting chest scar. In the assessment of complication rates between the reconstructed and augmented sides, the reconstructed side had a statistically significant higher rate of implant exposure (P = 0.04) and total complications (P = 0.02). In comparing the revision rates between these 2 groups, the need for implant change (P = 0.04) and the total revision rates (P = 0.01) were higher in the reconstructive side. Use of saline implants had a higher rate of chest wall and breast skin necrosis (P = 0.03) in comparison with silicone implants. There was not a statistically significant difference in complications when comparing timing of reconstructions (immediate versus delayed).

CONCLUSIONS

The CATS technique can be performed safely, with a desirable aesthetic outcome, and also symmetry with minimal risk of symmastia during unilateral breast reconstruction using implant-based reconstruction.

Functional and Volumetric Analysis of the Pectoralis Major Muscle After Submuscular Breast Augmentation

BACKGROUND

Dual plane breast augmentation is a technical variation of the submuscular plane described as a technique that reduces contour deformities due to contraction of the pectoralis major muscle and lower risk of double-bubble deformity associated with breast ptosis. Despite improvement in the aesthetic aspect, there is still no consensus whether this technique affects the function of the pectoralis major muscle.

OBJECTIVES

The aim of this study was to correlate functional with volumetric changes associated with dissection of the muscle origin in submuscular breast augmentation.

METHODS

Thirty women who desired to undergo breast augmentation were selected prospectively and randomly allocated to 2 groups: 10 patients in the control group and 20 patients in the interventional group, who underwent submuscular breast augmentation. Magnetic resonance imaging and volumetric software were used to assess muscle volume and isokinetic dynamometry was used to assess function of the pectoralis major muscle. Preoperative measurements were compared with those at 3, 6, and 12 months after surgery.

RESULTS

Magnetic resonance imaging revealed significant decrease in muscle volume at 6 and 12 months follow-up. The isokinetic test conducted during adduction showed a significant difference in muscle strength between groups from baseline to the 12-month follow-up, and between the 3- and 12-month follow-up. No significant differences in muscle strength during abduction were observed from baseline to the 3-, 6-, and 12-month follow-up.

CONCLUSIONS

Submuscular breast augmentation reduced muscle strength during adduction 12 months after surgery, but without a significant correlation with volumetric muscle loss.

LEVEL OF EVIDENCE 2

Secondary Breast Augmentation

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Assess common clinical problems in the secondary breast augmentation patient. 2. Describe a treatment plan to correct the most common complications of breast augmentation. 3. Provide surgical and nonsurgical options for managing complications of breast augmentation. 4. Decrease the incidence of future complications through accurate assessment, preoperative planning, and precise surgical technique.

SUMMARY

Breast augmentation has been increasing steadily in popularity over the past three decades. Many of these patients present with secondary problems or complications following their primary breast augmentation. Two of the most common complications are capsular contracture and implant malposition. Familiarity and comfort with the assessment and management of these complications is necessary for all plastic surgeons. An up-to-date understanding of current devices and techniques may decrease the need to manage future complications from the current cohort of breast augmentation patients.

The Use of "Precapsular Space" in Secondary Breast Reconstruction

BACKGROUND

Periprosthetic capsule formation is a physiological phenomenon occurring around breast implants. In case of capsular contracture, several surgical techniques are described; among them, total capsulectomy is considered the gold standard, but it is not free of complications. A more conservative procedure is the use of "precapsular space", leaving intact the preexisting capsule. The method presents minor complications and further advantages over total capsulectomy.

METHOD

From November 2010 to June 2014, we treated 92 postmastecttomy patients who previously underwent implant-based reconstruction. They presented implant malposition (bottoming-out, double bubble deformity, upward migration) and different degrees of capsular contracture. The implant was repositioned in a neoprecapsular pocket. Sixty-eight out of 92 patients presented a follow-up longer than 24 months, and they are included in the present study. They were evaluated with a questionnaire 1 month before surgery, at 6 months and 2 years postoperatively. Moreover, two independent plastic surgeons completed the same questionnaire at 6 months and 2 years after surgery.

RESULTS

Mean follow-up is 29 months. Baker III-IV capsular contracture occurred in 9.5 % of the patients, implant malposition in 2.9 % of the cases and no implant displacement rotation was observed. Patient self-assessment preoperatively and postoperatively (at 2 years) revealed improved cosmetic outcomes (p < 0.01). Surgeon assessment correlated with patient self-assessment.

CONCLUSION

The use of precapsular space, first described for aesthetic augmentation, is a valid alternative to total capsulectomy for the treatment of capsular contracture or implant malposition, even in the reconstructive field.

LEVEL OF EVIDENCE IV

This journal requires that the 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 .

Techniques to Repair Implant Malposition after Breast Augmentation: A Review

BACKGROUND

Implant malposition is a complication of breast augmentation that adversely affects aesthetic outcomes. It is one of the most common reasons for revisionary aesthetic breast surgery yet there is a lack of peer reviewed literature dedicated to the management of this complication.

OBJECTIVES

The purpose of this article was to summarize the malposition literature, review the types and causes of this complication, and evaluate the strengths and weakness of procedures aimed at addressing it.

METHODS

A review of the literature was performed using the PubMed database. Articles describing surgical techniques for correction of implant malposition, as well as outcome data for patients undergoing revision with described techniques, were included. Articles describing revisionary surgery following breast reconstruction were excluded. A series of cases are presented to illustrate techniques discussed.

RESULTS

Search criteria resulted in 763 articles. Title and abstract review followed by application of inclusion and exclusion criteria resulted in a total of 21 clinical studies from 1988 to 2014 that were included in this review. All studies included in this study were of level IV or V evidence.

CONCLUSIONS

Despite the overall low level of evidence in the literature regarding secondary breast augmentation, a thorough understanding of the corrective techniques presented will allow surgeons to make the most informed judgments. Weighing the strengths and weakness of these surgical techniques in the context of each patient will allow surgeons to develop the most appropriate treatment strategy. LEVEL OF EVIDENCE 4: Therapeutic.

Implant-based breast reconstruction with meshes and matrices: biological vs synthetic

This article presents an overview of the different acellular dermal matrices and synthetic meshes used in modern-day primary and secondary implant-based breast reconstruction. Case examples are given, along with a description of the senior author's pioneering direct-to-implant reconstruction.

Five-step Correction of Congenital Symmastia

Congenital symmastia is distressing and difficult to treat, and traditional surgical modalities have met with limited success. We present a novel approach for a patient that failed all traditional surgical options. The anatomic deformity is analyzed using a modified version of Blondeel’s 3-step analysis (conus, footprint, and skin envelope, to which we added a fourth element “intermammary web”). Combining operative principles from breast cancer reconstruction, we describe 5 operative steps that help correct the deformity, followed by a new postoperative splinting regimen that addresses the common pitfalls that could lead to recurrence.

Secondary augmentation-mastopexy: indications, preferred practices, and the treatment of complications

Increasing the volume of the breast while simultaneously decreasing the skin envelope equates to surgery involving opposing forces. Increasing patient demand and the evolving perceptions of surgeons have led to the growing popularity of the combined augmentation-mastopexy operation. In turn, secondary augmentation-mastopexies and revisional surgeries of primary augmentation-mastopexies also have increased in popularity. In this article, the authors describe indications for secondary augmentation-mastopexy, techniques for performing this combined procedure safely and effectively, adjunctive procedures, potential pitfalls, and the treatment of complications.

Thermal capsulorrhaphy: a modified technique for breast pocket revision

BACKGROUND

Scant attention has been paid to breast capsule revision after augmentation mammaplasty. Dissatisfaction with traditional techniques prompted the senior authors to develop a thermal capsulorrhaphy (TC) technique to obliterate excess breast pocket space using ball cautery followed by barbed suture closure.

OBJECTIVES

The authors propose a new periprosthetic technique for pocket closure, present a corresponding guide for surgical and postoperative management, and provide results of their retrospective review.

METHODS

Medical records were reviewed for all patients who underwent TC after cosmetic augmentation mammaplasty during a 5-year period, for whom clinical photographs were available from at least 1 year postoperatively. Operating details and complications were documented. Outcomes were rated a success, partial success, or failure, based on analysis of the photographs.

RESULTS

Of the 157 TC cases (41 unilateral, 58 bilateral) with a mean follow-up of 2 years, 141 (90%) outcomes were successful, 4 (2%) were partially successful, and 12 (8%) had failed. There were 16 complications: 10 over- or undercorrections and 1 episode each of hematoma, capsular contracture, slight deformity, nipple sensitivity, exposed suture knot, and suture abscess.

CONCLUSIONS

The efficacy of TC derives from the symbiosis of stitches and heat: capsulorrhaphy reinforces apposition of the damaged walls, and cautery contracts and thickens the capsule, thus reducing dead space and improving suture purchase. Initially popularized in shoulder surgery, TC is even better suited for breast pocket closure due to superior visibility and maneuverability, more aggressive practices, and the lack of similar complications. Postoperative stabilization and guideline compliance are essential to successful revision.

LEVEL OF EVIDENCE

4.

Porcine acellular dermal matrix (strattice) in primary and revision cosmetic breast surgery

BACKGROUND

Although acellular dermal matrix materials have been in use for over a decade in primary and secondary breast reconstruction and in some cosmetic breast surgery, little has been published on the outcomes of these materials for cosmetic applications.

METHODS

A retrospective institutional review board-approved review was conducted of all patients who had a specific acellular dermal matrix, Strattice, used for cosmetic breast surgery performed by the senior author (S.L.S.). Patient demographics, indications, surgical findings, and postoperative course were collected and data analyzed using descriptive statistical tools.

RESULTS

Between 2008 and 2012, Strattice was used in 43 cosmetic breast operations (75 breasts) performed by the senior author (S.L.S.). Sixty-nine of the 75 breasts (92 percent) were revision operations. Indications included inferior pole support [39 breasts (52 percent)], fold malpositions [28 breasts (37 percent)], capsular contracture [25 breasts (33 percent)], and rippling/palpability [six breasts (8 percent)]. Three patients (six breasts) had Strattice placed during primary augmentation/mastopexy. Seventy-four of the 75 breasts (98.7 percent) had successfully achieved the indication for which the Strattice was placed; one breast (1.2 percent) had some degree of relapse. The global complication rate for all patients in this study is 5.3 percent-two breasts (2.7 percent) had postoperative malposition, one breast (1.2 percent) had bottoming out, and one breast (1.2 percent) developed an infection that resulted in temporary device explantation.

CONCLUSIONS

The use of Strattice is safe and may be helpful in the management of certain situations in cosmetic breast surgery, including needed lower pole support, capsular contracture, rippling, and implant malposition.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Subcutaneous tissue expansion and subsequent subpectoral implantation for breast reconstruction in Asian patients: safety and outcome

Asian women are generally thin with smaller breasts. The objective was to investigate the outcomes for patients who underwent 2-stage breast reconstruction using subcutaneous expansion followed by subpectoral implantation. Between 2003 and 2008, 22 patients underwent subcutaneous expansion and subsequent submuscular implantation for 23 breast reconstructions. Mean age was 44.6 ± 7.0 years. The outcome was assessed with a pain visual analog scale, a questionnaire, and the cosmesis. Mean expansion volume was 350.3 ± 80.8 mL. Mean implant size was 306.7 ± 84.6 mL. The complication rate was 8.6%, 13.0% in first and second stages. Mean pain scale was 2 ± 1.4. At a mean follow-up of 42.5 ± 18 months, patient's satisfaction was 3.2 ± 0.9. Overall shape of the reconstructed breast was rated as 2.8 ± 0.5. Subcutaneous expansion with subsequent subpectoral implantation is feasible and reliable in low body mass index, nonsmoking, nonradiated patients with small and projective breasts.

Maximizing the use of precapsular space and the choice of implant type in breast augmentation mammaplasty revisions: review of 49 consecutive procedures and patient satisfaction assessment

BACKGROUND

Capsular contracture, implant malposition and displacement, breast asymmetry, improper contour, and symmastia may compromise the aesthetic outcome of breast augmentation and usually require surgical correction. Correction of these deformities may be achieved by accommodating a new implant in a novel pocket created in the precapsular space in either the subpectoral or subglandular plane. This article describes a modality to correct adverse results of augmentation mammaplasty and evaluates patient satisfaction.

METHODS

Precapsular reaugmentation was performed in 49 patients who underwent cosmetic breast surgery revisions from 2004 to 2009. All patients had previously received breast implants but complained of implant malposition and dislocation, implant size change, capsular contracture, and symmastia. A precise neoprecapsular pocket was developed above the old anterior implant capsule wall, with dissection limited to create only the space necessary for proper placement of the implant. Patients were evaluated for resolution of symptoms, satisfaction, and complications.

RESULTS

Implant malposition and rippling, capsular contracture, breast asymmetry, and symmastia were the most common complaints from the first augmentation. Nineteen women had subpectoral implant placement, 12 had subglandular, and the rest (n = 18) had "dual-plane" location of their implants. We used textured silicone implants in 17 cases and polyurethane-coated prostheses in the remaining 32 cases. The average follow-up time was 24.1 months. Breast augmentation-related complications had resolved in all patients without any recurrence to date. The overall complication rate was very low and patient satisfaction with this procedure was extremely high.

CONCLUSION

The creation of a neoprecapsular pocket combined in peculiar cases with the placement of polyurethane-coated implants is a versatile option that offers an effective one-stage solution for the correction of cosmetic mammaplasty-induced deformities.