Thermal capsulorrhaphy: a modified technique for breast pocket revision

Endoscopically Assisted Correction of Malpositioned Breast Implants Using Absorbable Barbed Sutures

INTRODUCTION

Breast implant malpositioning is the second most common reason for revisional breast surgery. Multiple correction methods are suggested, depending on the malposition, but most of the methods, such as the inframammary fold incision, result in additional scars. We performed transaxillary endoscopic breast implant bottoming out corrections and used V-Loc thread for capsulorrhaphy.

METHODS

Fourteen patients who underwent correction for breast implant bottoming out after transaxillary breast augmentation were included in this study. Transaxillary endoscopic correction was performed using a V-Loc thread.

RESULTS

All the 14 patients were satisfied with the result immediately after surgery. One case of overcorrection and one with implant bottoming out occurred, but did not require additional surgery.

CONCLUSIONS

Transaxillary endoscopic bottoming out correction is a useful technique for those individuals who underwent primary transaxillary incisional breast augmentation. V-Loc thread is useful for endoscopic capsulorrhaphy.

LEVEL OF EVIDENCE III

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 .

A New Technique for Breast Pocket Adjustment: Argon Beam Thermal Capsulorrhaphy

Implant malposition remains one of the main complications of aesthetic breast augmentation and alloplastic breast reconstruction with expanders and implants. Many capsulorrhaphy techniques have been described to adjust the breast pocket and correct the malposition. In this study, we tested the efficacy of the argon beam coagulator (ABC) for lateral capsulorrhaphy on breast reconstruction patients at the time of expander replacement with a permanent implant. We also experimentally compared the effects of the ABC and the standard electrocautery on fragments of healthy breast capsule. We noted a 69.5% capsule shrinkage with the ABC versus 46.8% with the standard electrocautery. We concluded that breast capsulorrhaphy using the ABC is a safe and efficient technique for the correction of breast implant malposition in both reconstructive and aesthetic breast surgery.

Revising Prepectoral Breast Reconstruction

SUMMARY

Prepectoral prosthetic breast reconstruction continues to gain popularity, largely due to its decreased postoperative pain, animation deformity, and operative time as compared to subpectoral reconstruction. Widespread use has led to opportunities for surgical revisions. While some techniques for submuscular reconstruction revisions, such as implant exchange and fat grafting, also apply to prepectoral revisions, others require modification for the prepectoral space. The prosthesis' unique reliance on the mastectomy flaps and acellular dermal matrix for support leads to a progressive alteration of the breast footprint, conus, envelope, and nipple-areola complex position. To date, revisions of prepectoral reconstructions have not been addressed in the literature. This article presents the senior author's (N.P.B.) techniques for (1) revising prepectoral breast reconstructions, including staged and direct-to-implant reconstructions, with a special focus on nipple-sparing reconstruction, and (2) minimizing undesirable outcomes of prepectoral reconstruction.

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.

Applying Principles of Breast Revision to Managing Aesthetic Patients with Textured Implants

SUMMARY

Textured breast implants have garnered increased attention recently because of their risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), an uncommon and treatable type of T-cell lymphoma. Treatment involves bilateral en bloc capsulectomy, which is curative in the majority of cases. At present, there is no defined management approach for aesthetic patients asymptomatic for BIA-ALCL requesting the removal of their textured implants, particularly as it relates to the management of the capsule. It is unclear if en bloc capsulectomy is necessary in these patients as it is in patients with BIA-ALCL. In the absence of clear guidance on the management of the capsule in asymptomatic patients, the basic principles of breast revision surgery can be applied to these patients.

Management of Symptomatic Patients with Textured Implants

SUMMARY

Proper management of symptomatic textured implant patients is critical to identify and treat associated oncologic disease. Textured surface breast implants were first introduced more than 50 years ago in an effort to decrease high rates of capsular contracture and implant malposition observed with first-generation smooth surface breast implants. Textured implants were dominant over smooth devices in the United States in the late 1990s, but they fell out of favor for newer-generation smooth implants, while texture remained the dominant selling implants worldwide until recently. A class I device recall by the US Food and Drug Administration in 2019 precipitated a removal of the highest selling implant worldwide, Allergan Biocell, due to a disproportionately increased risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Operative strategies, such as bacterial control at the time of textured implant insertion, have not been credibly shown to affect or prevent the future development of BIA-ALCL. BIA-ALCL patients require complete surgical excision of their disease, whereas textured implant patients who are otherwise asymptomatic do not require surgical removal. For suspicious cases, diagnostic testing with CD30 immunohistochemistry should be performed before any surgical intervention. Capsules are evaluated with 12 strategic regional biopsies in a standardized approach. If surgeons are revising or exchanging textured implants, they may reasonably consider a total capsulectomy, though this is not advocated by the Food and Drug Administration or national societies, and has not been shown to mitigate future risk of BIA-ALCL. The purpose of this article is to review data on and outcomes for textured surface implants, disease-associated risk, and the management strategy for revisionary surgery and device surveillance.

Elective Implant Removal and Replacement in Asymptomatic Aesthetic Patients with Textured Devices

SUMMARY

The management of patients with breast implants requires secondary procedures through the life of the implant, sometimes in the early postoperative period and more commonly many years after the initial surgery. In performing revisional procedures, removal and replacement of the implants is often required for a variety of reasons. With growing concerns of implant safety, implant exchange or removal with or without a capsulectomy has been increasingly requested by patients. In particular, textured breast implants have been under increased scrutiny secondary to their association with breast implant-associated anaplastic large cell lymphoma. Unfortunately, to date, there are no data and very little guidance as to the appropriate management of patients currently with textured implants as well as patients with a history of having had textured implants placed in the past. The surgeon must not only consider the appropriate management of patients with uncomplicated, asymptomatic textured devices but also consider the appropriate management when faced with another indication for revisional surgery and the need determine the appropriate course of action. An algorithm for the management of the explantation patient in general will be introduced in this review with a focus on the rationale, planning, and management of patients with an uncomplicated, asymptomatic textured implants.

Abdominoplasty in the Massive Weight Loss Patient: Are Aesthetic Goals and Safety Mutually Exclusive?

Background

The goals of abdominoplasty in massive weight loss (MWL) patients are often functional, with a greater emphasis on safety than on aesthetic rejuvenation. As important as functional improvements and safety are, however, there may be room for increasing the aesthetic potential of abdominoplasties in these patients.

Objectives

To determine the safety of the pursuit of aesthetic goals for abdominoplasty in MWL patients.

Methods

This is a retrospective study examining 910 consecutive female patients consisting of 3 groups: postpartum (n = 718), dietary MWL (n = 65), and bariatric MWL (n = 127). All patients were approached with a well-defined set of aesthetic goals which were pursued as needed and as feasible.

Results

The utilization of aesthetic abdominoplasty components was similar in all groups, supporting the assertion that the groups were subjected to a similar aesthetic emphasis. Logistic regression showed that a history of bariatric MWL was an independent risk factor for multiple complications (odds ratio 2.738, P = 0.014) and that elevated body mass index (BMI), smoking, diabetes, and age were likewise independent risk factors for complications. Propensity score-matched case-control pairs showed that bariatric MWL patients were more likely than dietary MWL patients to experience multiple complications (9.52% vs 0%, P = 0.031).

Conclusions

Bariatric MWL patients but not dietary weight loss patients seem to have a higher risk than postpartum patients. Other comorbidities (elevated BMI, smoking, diabetes, and age) seem to be more important predictors of complications than MWL status. Select MWL patients can likely be approached with an emphasis on aesthetic goals, without increasing risks as compared with the postpartum population.

Level of Evidence: 2

Popcorn Capsulorrhaphy in Revision Aesthetic Breast Surgery

BACKGROUND

Control of the pocket in revisional breast surgery can be technically challenging and unpredictable. A capsulorrhaphy technique has been utilized in altering capsules in secondary aesthetic breast surgery.

OBJECTIVES

The authors sought to determine the effectiveness of popcorn capsulorrhaphy in revisional breast surgery.

METHODS

A retrospective chart review of revisional breast cases utilizing popcorn capsulorrhaphy was conducted between September 2015 and August 2017. Only aesthetic breast cases were included. Data were collected for 149 patients.

RESULTS

One hundred forty-nine patients representing 266 breasts were operated on. The average patient age was 42 years and the mean body mass index was 24.2 kg/m2. The average time from their original surgery to the popcorn capsulorrhaphy secondary procedure was 9.3 years. Indications for capsulorrhaphy included malposition in 163 breasts (61.3%), implant positioning for breast ptosis in 34 breasts (12.8%), pocket adjustment for implant size change in 49 breasts (18.4%), and postexplantation pocket reduction in 20 breasts (7.5%). Of the 266 implants, 145 (54.5%) were smooth, 101 (38%) textured, and 20 (7.5%) were explanted. The average original implant size was 405 cc and the average size placed at the time of capsulorrhaphy was 422 cc. Two hundred thirty-six (88.7%) were in a submuscular pocket and 30 (11.3%) were subglandular. The total number of complications was 39 (14.7%), and 16 (6%) required some type of operative revision.

CONCLUSIONS

Popcorn capsulorrhaphy can provide pocket control and stability with low complication and revision rates. The addition of a mesh or biologic at the time of popcorn capsulorrhaphy can further lower the complication and revision rates.

LEVEL OF EVIDENCE: 4

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.

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.