Revisions for Complications of Aesthetic Breast Surgery

Abstract

Breast surgery continues to be one of the most sought-after cosmetic procedures in recent years. Patients are opting to undergo various procedures to enhance the aesthetics and appearance of their breasts. The goal of any cosmetic procedure is to compliment one’s body and achieve satisfactory results. However, some patients may experience complications or become dissatisfied with the final result. These complications include breast asymmetry, implant malposition, implant deflation, rippling, and capsular contracture. Aesthetic breast revision is a highly specialized procedure that requires an experienced surgeon, aiming to address the patient’s concerns as well as achieve a more desirable outcome.

1. Introduction

Breast surgery is one of the most sought-after cosmetic treatments with breast augmentation being the most common aesthetic procedure [1]. Patients may undergo various procedures to enhance and improve the appearance of their breasts. Breast surgery can be divided into breast augmentation with the use of implants or autologous fat transfer, mastopexy, reduction mammaplasty, or a combination of these procedures. The aesthetic outcomes rely on postoperative breast symmetry, size, and shape. Beauty is in the eye of the beholder, and it is greatly influenced by an individual’s perception, as well as symmetrical balance. Aesthetic breast surgery is the congruence of science and art based on the relationship between human morphology and anthropometric proportions.

As with any procedure, there are associated risks with breast surgery including asymmetry, rippling, implant malposition, implant deflation, or capsular contracture. The goal of aesthetic revisional breast surgery is to address the unsatisfactory result or complication of the previous breast surgery and produce an aesthetic result. The benefits of revisional breast surgery are numerous. Patients can achieve a more desirable breast size and shape, correct any complications from previous breast surgery, and improve their self-confidence and body image.

However, revision breast surgery is not without risks. The surgery carries the same risks as other surgical procedures such as bleeding, infection, and anesthesia complications. The risks of revision surgery are greater than the risks of the initial breast surgery due to the presence of scar tissue, altered anatomy, and compromized blood supply, increasing the risk of tissue/nipple necrosis.

Aesthetic revision breast surgery is a complex procedure that requires a skilled and experienced surgeon to achieve optimal results. Patients should carefully research potential surgeons and choose a surgeon who has extensive experience performing breast revision surgery.

The surgical aspect of breast surgery continues to evolve over time with advancements in surgical techniques and a greater knowledge of anatomy and its variants. The surgeon must have an armamentarium of surgical techniques to offer treatment that promises both aesthetic results and longevity with marginal risk of complications. As the technical aspect of surgery improves, knowledge of the anatomy is the single aspect of breast surgery that remains consistent. Being equipped with this knowledge allows the surgeon to identify and preserve important structures, therefore decreasing the risk of complications and improving the final outcome.

2. Preoperative planning

The preoperative patient appointment is one of the most important steps in the breast revision process. Most patients seek evaluations from multiple surgeons, and it is crucial to make a great impression. The goal of the consult is to determine the patient’s surgical goals, obtain medical information, perform a physical exam, develop a diagnosis, explain the recommended procedures with associated risks and benefits, and address the patient’s expectations. It is the appointment where patients should be properly educated about the condition(s) and procedure options while establishing realistic expectations.

2.1 Patient evaluation

Preoperative evaluation of a patient is vital to any surgical procedure. First and foremost, it is imperative to review the patient’s medical history and chief complaint. The chief complaint is the primary topic of discussion and must be in the patient’s own words. The patient should be able to describe their concerns and may be guided with open-ended questions. A thorough evaluation should include medical diagnoses, medications with proper dosages and frequencies, allergies, and past surgical history. The patient’s social history must be obtained, and the discussion must focus on the use of tobacco or nicotine-containing products due to concerns of compromised vasculature and wound healing. Finally, social history should include the patient’s profession as the patient may have restrictions of their work-related duties. Lastly, the surgeon should determine if there is any family history of cancer, as well as any previous mammograms. Those patients over the age of 40 or patients who are of high risk should undergo a mammography prior to surgery [2].

2.2 Patient examination

The physical examination begins with a visual inspection of the breasts. The key areas to evaluate during the breast examination are the skin envelope (laxity and quality), breast volume, position of the nipple-areola complex, areolar size, degree of ptosis, asymmetries, and pocket location of the implants. Mallucci and Branford stated the four pivotal elements in breast aesthetics are: proportion of the upper pole to lower pole, angulation of the nipple, upper pole slope, and lower pole convexity [3].

The surgeon must be able to identify any asymmetries, implant malposition, and size discrepancies. It is important to note that a size difference of <10% is considered within normal limits [4]. Aside from breast morphology, the surgeon must also identify any deformities of the chest or spine that may lead to an asymmetry. Lastly, the breasts and axilla should be palpated to evaluate for the presence of masses or lymphadenopathy, including the associated lymphatic chain of the supraclavicular and axillary lymph nodes.

A grading system to evaluate breast ptosis was developed by Dr. Paule Regnault. The grade of breast ptosis is determined by the position of the nipple in relation to the inframammary fold (IMF) and skin envelope (Figure 1, Table 1) [5].

Figure 1.

Breast ptosis classification [5]. A: normal, B: 1st degree, C: 2nd degree, D: 3rd degree, and E: glandular ptosis.

Regnault’s classification of ptosis
Minor ptosis (1st degree)	Nipple at the IMF or 1 cm inferior to IMF
Moderate ptosis (2nd degree)	Nipple inferior to IMF & superior to lower breast contour
Severe ptosis (3rd degree)	Nipple inferior to IMF & at lower breast contour
Glandular ptosis	Nipple superior to IMF & breast tissue inferior to the breast fold
Pseudoptosis	Nipple superior to IMF; breast is hypoplastic and inferior to the breast fold

Table 1.

Regnault’s classification of breast ptosis [5].

The last part of the examination involves obtaining breast measurements and photos (Figure 2). These measurements include: [3, 4, 6, 7, 8].

1. Breast width (BW): Measurement of the most medial to the anterior axillary line

2. Breast thickness (BT): Measurement of the thickness of the upper pole

3. Sternal notch to nipple (SN-N): Ideal measurement of 19–21 cm

4. Mid-clavicle to areola (MC-A): ideal measurement of 19–21 cm

5. Inter-nipple distance: Ideal measurement of 19–21 cm

6. Areolar width (AW): Ideal measurement of 3.5–4.5 cm

7. Nipple to inframammary fold (N-IMF): Ideal measurement of 7–8 cm

8. Intermammary distance (IMD): Ideal measurement of 21 cm from nipple to nipple

9. Ptosis: Nipple position in reference to inframammary fold

10. Mid-humeral point (MHP): Mid-point between the acromion and lateral epicondyle and the ideal location of the nipple

11. Breast parenchyma size: Lower pole is greater than the upper pole.

12. Skin quality

13. Parenchyma quality and elasticity

Figure 2.

Breast measurements and ‘ideal’ base width.

The most crucial measurements in breast revision surgery are the breast width, sternal notch to nipple, and nipple to inframammary fold. The ‘ideal’ or desired base width (BW) is typically different from the actual BW of the native breast tissue and can most often be measured as the distance from the anterior axillary line to within 1 cm from the chest midline. The goal or desired base width for the patient is used during implant sizing to achieve the ideal implant width (Figure 2). The breast width measurement assesses for the maximal implant width to avoid symmastia or lateral position of the breast implant. The nipple to inframammary fold measurement is critical to establish an esthetic lower pole fullness and overall breast shape. The sternal notch to nipple measurement determines the location of the nipple-areolar complex on the chest wall [6]. The surgeon must acknowledge these measurements and respect the limitations of the breast tissue.

The preoperative evaluation is imperative in order to allow for the surgeon to develop a sound surgical approach to achieve the best aesthetic outcome.

2.3 Patient discussion

The patient and the surgeon must be aware that no breasts are similar in shape and size and furthermore, breasts are rarely perfectly symmetrical. The surgeon must address the patient’s desires while maintaining sound surgical parameters. The patient should be an active participant in the consultation by providing the chief complaint and expressing the desired outcomes. A well-educated patient understands the indications for various procedures and is aware of any limitations or possible complications. This assures a great provider patient experience with an aesthetic outcome.

3. Surgical complications

3.1 Implant malposition

Breast asymmetry is a common phenomenon in which there is a difference in shape, size, and/or position between each breast. One of the most common causes of asymmetry is implant malposition.

Implant malposition can occur due to improper implant selection, inadequate tissue support, or surgical error. The implant may shift in a superior, medial, inferior, or lateral direction. Shifting may be due to an inadequate or excessive pocket size, as well as poor tissue architecture.

Superior displacement is due to inadequate release of the inferior aspect of the breast pocket, causing the implant to slide upwards. Medial displacement creates symmastia (confluence of the breasts) due to excessive medial dissection of the breast pocket. Over dissection of the inferior aspect of the breast, poor tissue support, or large implants may lead to inferior displacement of the implant, resulting in thinning of the breast tissue and skin, as well as ptosis.

Lateral malposition is one of the most common types, where the implant is positioned along the armpits, creating a wide gap between the breasts. Over time, these implants may cause pain or tenderness and may be palpable and visible. Additional causes of implant malposition include trauma, capsular contraction, or aberrant anatomy.

To minimize the development of implant malposition, the surgeon must be thorough with the initial surgical planning. The surgeon must focus on selecting the proper implant that does not violate the natural breast width, complementing the patient’s body, and avoiding over/under dissection of the breast pocket. Postoperatively, patients must adhere to minimizing strenuous activities for several weeks to avoid disruption of the breast pocket, as well as utilizing compression garments to maintain the position of the implants.

3.2 Capsular contracture

Following breast augmentation, the body develops a capsule or scar tissue around the implant. A healthy breast capsule is soft and assists with maintaining the breast implant in its position. Capsular contracture develops when the body’s immune system has an increased sensitivity to the implant or is activated in response to the presence of a bacterial biofilm or blood, producing a thickened and tightened breast capsule. This may lead to distortion of the breast shape, hardening of the breast, pain, and tenderness.

The exact mechanism of capsular contracture is unknown. However, steps may be taken to reduce the incidence of capsular contracture. Surgically, the surgeon must adhere to proper sterile techniques and minimize direct handling of the implant. The breast pocket must be free of any active bleeding, as well as residual blood. The implant should be washed with sterile saline and a triple antibiotic solution to reduce the formation of a biofilm. Patients are instructed to avoid direct contact with the breasts and adhere to postoperative instructions. Prophylactic montelukast or zafirlukast has shown to reduce the incidence of capsular contracture by reducing inflammation around the implant [9]. The incidence of capsular contracture cases requiring revision surgery is 10% at 10 years, with a decrease prevalence in implants placed in a submuscular plane [10].

3.3 Implant rippling/deflation

Implant rippling is due to the folding of the edges of the implant creating a visible wrinkle along the skin. Implant rippling occurs more often in patients with thin breast tissue (minimal tissue coverage), as well as inadequately filled implants (edges of the implant will fold over itself).

Implant deflation may be caused by a rupture or leak leading to the loss of the implants size and shape. Immediate deflation is more common with saline implants creating a drastic change in the breast appearance, while rupture of silicone implants may not cause any changes. Potential causes of implant deflation are a manufacturing defect, trauma, or weakening of the implant capsule.

Prevention of implant rippling/deflation focuses on selecting an appropriate implant size, cohesiveness, and pocket position to allow for adequate soft tissue coverage.

4. Breast revision

Upon completion of the patient examination, the surgeon must determine what is the best procedure to address the patient’s concerns and rectify the complication.

4.1 Post-augmentation breast ptosis

Following augmentation, a “waterfall effect” may form due to the sliding of breast tissue (ptosis) over the fixed implant [11]. Options for correction of ptosis include implant exchange, removal of implants, mastopexy, or no treatment.

If the patient is happy with the position, shape, and cleavage of the breasts, no surgical intervention is required.

For patients who are unhappy with the shape and position of the breasts, a decision is to be made whether to place a larger implant or shift the implant pocket to a sub-glandular position. The surgeon must be mindful that if lower pole ptosis is present, switching to a sub-glandular position will cause the ‘waterfall effect’ to persist.

The most definitive treatment to address the “waterfall effect” is a mastopexy. The breast mastopexy aims to recreate a symmetrical, appropriately sized breast while reducing breast ptosis [6]. The procedure involves elevating the nipple-areolar complex (NAC) in addition to removing excess skin and breast tissue. The mastopexy incision depends on the degree of ptosis and desired outcome (Table 2).

Mastopexy incision design	Indications	Advantages	Disadvantages
Periareolar/crescent	Grade I or II ptosis and nipple asymmetry	NAC elevation 1–2 cm Camouflaged scar	Decreased projection of breast mound Scar Widening
Vertical/teardrop	All ptosis grades	Correction of ptosis and resection of excess tissue Preservation of nipple mound projection	Possible persistent asymmetry Decreased lower pole projection
Wise pattern/inverted T	Grade II or III ptosis	Increased resection of breast parenchyma and skin Allows for breast reduction and lift in conjunction with augmentation	Increased scar presence Increased suture spitting

Table 2.

Mastopexy design [12].

4.1.1 Periareolar/crescent

The periareolar technique may be utilized in patients who with Grade I/II ptosis or nipple asymmetry and mild skin excess. This technique allows the surgeon to elevate the nipple-areolar complex within 2 cm, with minimal reduction of redundant tissue or skin. This procedure assists with balancing out the nipples with minimal effect on the breast parenchyma. In regard to reduction of the skin envelope, a periareolar defect may develop and lead to poor wound healing, distortion of the NAC, and decreased breast projection [6].

The downside of this procedure is the postoperative periareolar widening. Two methods may be utilized to reduce this risk. First, maximal stretch should be applied while creating the incision to minimize the effects of the immediate postoperative stretching. Second, the use of a permanent purse-string suture for closure of the incision. This allows for stress absorption by the suture and reduction in tension along the areola. The most common suture used is a polytetrafluoroethylene (PTFE) suture [6].

The crescent mastopexy is a modified version of the periareolar technique that includes resection of circumareolar breast tissue. The crescent incision may be utilized in patients with an asymmetrical nipple or those requiring NAC elevation of 1–2 cm.

Benelli discussed a periareolar mastopexy that incorporates parenchymal restructuring [13]. This procedure allows the surgeon to reduce larger breasts while utilizing the periareolar approach. The inferior breast parenchyma is excised vertically, and the parenchymal pillars are repositioned to reduce the fullness of the lower pole while simultaneously elevating the breast position.

Based on the authors’ belief and the literature, periareolar mastopexies have an increased rate of revision due to undesirable results such as poor esthetics, inadequate projection, and high recurrence rates [12, 14].

4.1.2 Vertical-teardrop

The vertical mastopexy focuses on repositioning the NAC and correcting breast ptosis by allowing for excision of glandular tissue, ultimately improving the longevity of the procedure. This mastopexy involves a periareolar incision with a vertical component.

The Hall-Findlay technique is frequently used due to the versatility in pedicle design, minimal scar presence, and improved projection. This technique is supported by a superior-medial-central (SMC) or a medio-central (MC) pedicle due to its robust arterial supply and venous drainage. A wedge resection of the inferior pole breast parenchyma is performed, while the remaining medial and lateral pillars are re-approximated to provide support to the NAC, ultimately reducing the breast volume and elevating the breast [15]. Of note, the inferior aspect of the vertical incision must be placed superior to the inframammary fold (IMF) to avoid an incision along the abdomen; this is due to the tendency of the IMF to elevate with time.

For implant pocket selection, a sub-glandular or sub-pectoralis implant placement is both viable options, this is due to the preservation of the 2nd/3rd internal mammary perforators [12]. With this technique, the breast will have moderate upper pole fullness with a compressed inferior pole. It will take several months for the implant to settle and the inferior pole to develop its shape.

4.1.3 Wise pattern/inverted T

The Wise Pattern/Inverted T is one of the most versatile mastopexy techniques allowing for a large reduction of both breast parenchyma and skin with simultaneous implant placement. This technique allows for a multitude of pedicle options, including inferior, superior, medial, central pedicles, or a combination [14]. This mastopexy consists of two components: the vertical and horizontal incisions. The vertical incision allows for elevation of the NAC, as well as reduction of the inferior pole. The horizontal incision allows for excision of ptotic skin/breast parenchyma while controlling the nipple to inframammary fold distance; this ensures an aesthetic lower pole shape.

The surgeon must be aware of the limitations of this technique. If an inferior pedicle is utilized, there is an increased incidence of redundant inferior breast pole or bottoming out of the implant due to a reduced pillar of support along the inferior pole [16]. An additional concern is the significant scarring compared to the previously discussed techniques. When performing a combined mastopexy and augmentation, there is an increased incidence of tissue dehiscence along the trifurcation due to the weight of the overlying implant [12].

4.1.4 Surgeon’s preference

With revision surgery, the surgeon must develop a definitive plan and inform the patient of potential complications. All prior operative reports should be obtained to determine the original planes of dissection and selected pedicle design, reducing the risk of further complications. In cases where the pedicle design is unknown, a pedicle design with multiple perforators is ideal. The superomedial-central (SMC) is the surgeon’s preferred pedicle for SN-N distances less than 30 cm due to the robust blood supply both medially and centrally (Figure 3).

Figure 3.

Superomedial-central pedicle. This pedicle design demonstrates the excellent dual blood supply to the breast and NAC via medial, as well as central perforators.

The surgeon must be aware of various pedicle designs and their appropriate applications (Figure 4). The superior-medial pedicle (SM), when combined with a central pedicle (C), is the most versatile pedicle due to its robust blood supply. The pedicle is perfused by the internal mammary artery in addition to the 2nd-4th internal mammary perforators (superior-medial-pedicle) and the trans-pectoral perforators off the internal mammary and medial mammary branches (central pedicle). The minimal base width of the pedicle is 6–10 cm, ensuring adequate perfusion. If the patient has undergone previous augmentation with placement of the implant in a sub-glandular plane, the blood supply of the central pedicle is no longer viable (Figure 5).

Figure 4.

Breast pedicles. The pedicle designs demonstrate the robust blood supply to the breast and NAC.

Figure 5.

Pectoral vessels. Sub-mammary pocket development disrupts the perforators to the central pedicle. A total submuscular implant placement preserves the perforating pectoral branches to the central portion of the pedicle even with major inferior gland excision.

The authors may select to utilize a different pedicle design depending on the surgical circumstance. For those patients with severe ptosis/pendulous breasts (SN-N > 30 cm), a medio-central (MC) pedicle allows the pedicle to rotate superiorly while preserving the vasculature and minimizing tension. The medio-central pedicle is perfused by the internal mammary artery and the arterial perforators (Figure 6) [17]. In cases of mild to moderate ptosis (NAC positioned 2–3 cm inferior to the IMF), a superior-medial-central (SMC) allows for improvement of upper pole fullness and shape. This pedicle is perfused by the lateral and internal mammary arteries, as well as a branch of the axillary artery; this robust blood supply reduces the risk of wound dehiscence [17].

Figure 6.

The superomedial pedicle. The SMC pedicle is utilized for most mastopexy cases. For patients with a SN-N greater than 30 cm, a MC pedicle is preferred due to its ease of rotation of the NAC with minimal constriction.

In regard to implant pocket selection, the authors routinely select a total submuscular plane. The total submuscular plane preserves the blood supply to the overlying pedicle while providing a layer of protection over the implant. The additional soft tissue coverage decreases the incidence of capsular contracture. The surgeon must properly prepare the pocket and ensure adequate release of the muscle. Improper release of the pocket may lead to a superiorly positioned implant creating significant upper pole fullness with a downward rotation of the NAC [6]. Additional pocket development below the serratus anterior and external obliques allows for additional coverage along the lateral and inferior aspect of the implant, increasing the support around the implant (Figures 7 and 8). The surgeon must avoid excess dissection along the medial, inferomedial, and inferior aspects to avoid symmastia, boxy appearance of the medial breast and inferior displacement of the implant, respectively [6].

Figure 7.

The superomedial-central pedicle. The use of the SMC pedicle allows for the development of a total submuscular pocket. The submuscular pocket allows for complete coverage of the implant; this protects the implant as well as reduces the risk of bottoming out.

Figure 8.

Total submuscular pocket. Digital dissection allows for the development of a total submuscular flap. The surgeon must take caution during the dissection to avoid perforation of the flap, most specifically along the inferior aspect.

The most conservative approach to combined mastopexy and augmentation is for placement of the implant followed by the mastopexy. This permits for adequate parenchyma resection and skin removal. The authors proceed with the mastopexy followed by the augmentation. When performing the mastopexy first, the surgeon is able to create a total submuscular pocket and manipulate the breast tissue to improve the breast contours, as well as the implant projection. The skilled surgeon must properly plan the resection margin and select the appropriate implant in the preoperative appointment to avoid excess tissue/skin removal risking necrosis.

4.2 Implant malposition

Another complication is implant malposition, seen in both primary augmentation and combined augmentation/mastopexy. The implant is commonly displaced inferiorly and laterally can be addressed with pocket modifications, including capsulorraphies/capsulectomies.

Breast capsulorrhaphy, also known as an internal bra lift, is a surgical procedure, where the breast capsule is repaired and tightened. Capsulorraphy may be performed utilizing a multilayered suture, thermal energy, mesh, or a combination of these techniques. Spear discussed utilizing a multilayered suture with an absorbable or non-resorbable suture allowing for correction in multiple increments and reducing stress on each individual suture [18]. “Popcorn” capsulorraphy was first described by Randquist. With this procedure, thermal energy is applied to the capsule, tightening and reshaping the pocket [19]. The Gala FLEX mesh scaffold is composed of resorbable poly-4-hydroxybutyrate monofilament fibers. The mesh provides an internal support along the breast capsule [20]. The scaffold allows for tissue ingrowth creating a vascularized tissue bed that integrates with the native tissue. The scaffold yields a final tissue strength three to five times stronger than native tissue, creating a more supported pocket [21].

For correction of the malposition implant, the authors utilize the multilayered suture technique into addition to the “popcorn” capsulorraphy. Preoperatively, the patient is evaluated in a standing position, and the proposed capsulorrpahy is performed and marked on the skin. It is also important to mark the areas of proposed capsulotomy to allow for re-positioning and decrease the pressure on the area of repair. Intraoperatively, an incision is made along the previous inframammary incision and the breast capsule is entered. The implant is removed and evaluated to ensure that the implant is intact. Next, following the planned capsulorraphy, a Bovie cautery is utilized to score the capsule internally. This process creates a “popping” sound as the energy is applied to the breast capsule. Then, a suture capsulorraphy is performed along the treated area using a one Nurolon in a continuous-locking fashion. Once this is complete, mirroring capsulotomies are performed. The capsulotomies are performed opposite of the capsulorraphy, as well as along the anterior aspect of the capsule to allow for adequate repositioning. Upon completion of the capsulorraphy/capsulotomy, the pocket is irrigated with triple antibiotic solution and betadine. The implant is re-inserted, the pocket is re-approximated, and the patient is placed in a beach chair position to confirm symmetry. Once symmetry is achieved, the patient is placed in the supine position, and the incision is closed in a layered fashion (Figure 9).

Figure 9.

Inferior displacement of the breast implants. The patient underwent previous breast augmentation and was unhappy with the “droopiness” of her breast tissue, as well as the position of the breast implants. The patient underwent a simultaneous lift and revision augmentation. A capsulorraphy was performed to reposition the breast higher on the chest wall.

Some cases that have malpositioned implants above the muscle required removal and replacement into a near pocket below muscle. Some surgeons elect to use an ADM from the lateral border of pectoralis to prevent slippage of the implant back above muscle. However, the use of a total submuscular pocket in these cases prevents unwanted implant migration without the need for a costly ADM. The new total submuscular position is much easier to achieve when the patient requires a simultaneous mastopexy. The surgeon must use caution since the blood supply to the NAC has been compromized from their previous sub-mammary augmentation (Figure 10).

Figure 10.

Replacement above to below muscle. The patient shown is before and 3 months after switching implants from saline to silicone and changing her pocket from above muscle to a total submuscular position along with a simultaneous breast lift. The implants have a larger base width to further improve cleavage. The “total” submuscular placement produces improved implant coverage while also preventing slippage of the new implant into the old sub-mammary pocket.

For difficult cases where there is a high risk of malposition recurrence, a mesh may be placed to reinforce the capsule. Prior to placement of the mesh, fascial flaps are prepared along the planned surgical area. The flaps will provide coverage over the mesh. The Gala FLEX mesh is placed along the weakened capsule or the area of a tissue deficit. Once properly positioned, the mesh is secured to the capsule and pectoralis muscle. Additional support may be provided by securing the mesh to the ribs. The authors utilize a 0 Vicryl in a continuous running fashion to secure the mesh to the underlying tissue, as well as ribs, recreating the internal support. Next, the mesh is fixated to the overlying fascial flap to provide additional soft tissue coverage using a 0 Vicryl.

For those patients with compromized soft tissue coverage, localized muscle flaps are a viable option for breast reconstruction to provide implant coverage and restore tissue defects (Figures 11 and 12).

Figure 11.

Soft tissue reconstruction. Patient with previous mastectomy and radiation. Patient developed tissue necrosis with exposure of her rib. A latissimus dorsi flap (myocutaneous flap) was utilized to reconstruct the right breast tissue. Breast implant expanders were placed after surgery followed by final implants and nipple tattooing.

Figure 12.

Multiple breast revision surgeries. The above patient had undergone several breast augmentations with the final augmentation complicated by symmastia. The overlying muscle was significantly damaged and an inferolateral submuscular flap (serratus and external oblique muscles) was developed to obtain coverage over the new implant.

4.3 Capsular contracture

Capsular contraction develops due to the excess scar formation around the breast implant causing hardening and distortion of the breast. Risk factors associated with the development of capsular contracture are a history of capsular contracture, sub-glandular implant placement, silicone rupture, smoking, bacterial contamination, and autoimmune disorders. Development of contracture is a continuous process that can present several years after implant placement [22].

Evaluation for capsular contracture is based on clinical exam. The provider must assess for any changes in the breast symmetry, texture, and appearance, as well as the patient’s symptoms (Table 3). Additional modalities, ultrasound or magnetic resonance imaging (MRI), may be utilized to assess the extent of contracture and implant integrity.

Baker grade	Breast description	Implant description	Treatment
I	Soft, normal shape	Non-palpable	No treatment
II	Firm, normal shape	Palpable, not visible	Nonsteroidal anti-inflammatory medications, Montelukast, capsulotomy
III	Firm, slight distortion	Palpable, visible	Capsulectomy, implant exchange
IV	Hard, severe distortion	Palpable, visible	Capsulectomy, implant exchange

Table 3.

Baker grade of capsular contracture [23].

Treatment of breast implant capsular contracture is based on the clinical presentation. In mild cases, the patient may be instructed to monitor for any progression of the capsular contracture, perform daily massages to soften the breast capsule, or take medications such as montelukast to reduce inflammation.

For moderate to severe cases (Grade III/IV), the surgeon must intervene to improve the patient’s outcome. Surgical options include capsulotomy, capsulectomy, implant pocket change, use of acellular dermal matrices (ADM), or soft tissue/muscle flaps [24]. Studies demonstrate a success rate of 79% for reoperation with implant exchange. However, the recurrence rate is approximately 54% [25].

For correction of severe capsular contraction, the surgeon prefers to remove the capsule and implant en bloc to avoid silicone leakage into the breast cavity. The previous implant must be removed due to the concern for possible biofilm embedded along the implant shell. Once the affected capsule has been removed, the surgeon must determine the location of the previous implant pocket. If the implant was in a sub-glandular plane, a submuscular pocket will be developed to house the new implant. If a submuscular plane was utilized previously, the surgeon must determine the integrity of the remaining pectoralis pocket and whether an ADM or tissue flap must be utilized to recreate the breast pocket (Figures 13 and 14).

Figure 13.

Grade IV capsular contracture. Patient with grade IV capsular contracture. Patients with capsular contraction who desire a breast lift with augmentation must be informed of the high revision rate and risk of complications.

Figure 14.

Grade IV capsular contracture. Patient with grade IV capsular contracture. Patient underwent en bloc capsulectomy with simultaneous breast lift and augmentation.

Acellular dermal matrix may provide a protection against capsular contracture. Studies demonstrate a decrease in blood vessel proliferation, fibroblast activity, fibrosis, and collagen deposition in addition to decreasing the inflammatory response of the body [26, 27].

Prior to placement of the mesh, soft tissue flaps are prepared along the planned surgical area. The flaps will provide coverage over the mesh. The Gala FLEX mesh is placed along the weakened capsule or the area of a tissue deficit. Once properly positioned, the mesh is secured to the underlying tissue and pectoralis muscle. Additional support may be provided by securing the mesh to the ribs. The authors utilize a 0 Vicryl in a continuous running fashion to secure the mesh to the underlying tissue, as well as ribs, recreating the internal support. Next, the mesh is fixated to the overlying fascial flap to provide additional soft tissue coverage using a 0 Vicryl (Figure 15).

Figure 15.

Recurrent capsular contracture and use of ADM. Patient had developed grade IV capsular contracture following four previous breast augmentation surgeries. Upon evaluation by the authors, residual implant pockets were discovered, in addition to a rolled pectoralis muscle and calcified capsules. The excess scar tissue/capsules were excised, and the pocket was reconstructed with an ADM. The ADM was attached to the inferior edge of the pectoralis muscle and secured to the rib at the desired IMF. A vertical mastopexy was simultaneously performed.

Routine and long-term follow-up is imperative to ensure proper healing and monitor for signs of contracture recurrence.

4.4 Implant rippling/deflation

As previously stated, breast implant rippling occurs when the implant borders fold, resulting in visible wrinkles on the skin. Surgeons must be prepared to offer both minimally invasive and invasive surgical options to address this issue.

Autologous fat grafting can be performed to provide additional volume and soft tissue coverage, particularly in patients with minimal breast thickness. However, there are two main concerns associated with breast fat grafting: variable resorption of the grafted tissue and potential increased cancer risk [28].

Studies have shown that the absorption rate of autologous fat grafting ranges from 20 to 90%, with an average retention of approximately 50% [29, 30]. Complications, such as fat necrosis and oil cyst formation leading to nodules, can occur following grafting. It is important for patients to be informed that around 40–60% of the graft may resorb over a 3–6-month period and that additional grafting sessions may be required to achieve the desired outcome.

Regarding the risk of oncologic transformation, research has indicated that there is no significant increase in tumor recurrence after fat grafting following breast-conserving therapy or mastectomy [31, 32].

During the procedure, fat is harvested from another area of the body and transferred to the breast, enhancing its shape, contour, volume, and thickness. To ensure adequate vascularization, it is recommended to place small amounts of fat along the pectoral and supra-pectoral plane. Surgeons should avoid large-volume grafting to minimize the risk of increased graft pressure, leading to tissue damage and necrosis [33, 34].

Implant exchange is a more invasive option, where the previous implants are removed and replaced by a more cohesive implant. Breast implant cohesiveness is defined as the consistency of the breast implant silicone gel, ranging from low to high cohesiveness. Silicone cohesiveness is determined by the amount of cross-linking of the silicone molecules, providing a stable and solid gel consistency [35]. Selection of the proper implant cohesiveness is based on the patient’s desired outcome. High-cohesive implants are ideal for those that desire a more defined and upper pole fullness, while low/moderate cohesive implants provide a more natural feel and adequate shape maintenance. In addition to maintaining the implant shape and fullness, high cohesive implants have a decreased risk of leakage due to their solid-like gel structure.

In cases where implant rippling is due to sub-glandular placement, conversion to a subpectoral plane allows for additional soft tissue. The subpectoral plane allows for additional implant support and reduces the appearance of rippling. A combination of pocket exchange, high implant cohesiveness, and autologous fat grafting may provide an excellent aesthetic result in those patients with minimal soft tissue coverage. While increased cohesiveness offers advantages, such as reduced gel bleed, in the event of rupture, it comes at the expense of implant softness, directly affecting the tactile sensation of the reconstructed or augmented breast [36].

4.5 Complex breast (constricted, asymmetric, and massive ptosis)

Certain breasts are simply challenging from the very start even before any other previous breast surgery. Some of the most common complex issues from a virgin breast involve constricted or tubular breast, severely asymmetric breast, and /or extreme ptosis, such as massive weight loss (MWL) surgery.

Asymmetric breast should not merely be treated with a larger implant on the smaller breast. Our goal is to achieve the most symmetry as possible including both shape, size, and NAC position. To do so typically requires removing the “excess” volume from the larger breast to match the smaller breast while positioning the NAC at the same location on the breast mound. If implants are required, then in most cases the same size implants can be used on both sides after the native breast tissue is made to be the same size. The exception for placing different size or different profile implants often is only for cases where the chest wall (ribs) is very different on one side vs. the other requiring a higher profile implant on the sunken side due to the bony deformity (Figure 16).

Figure 16.

Asymmetric breast treatment. Treatment of severe breast asymmetry is typically best treated by removing the “excess” tissue from the larger breast as shown in each case above. The same size implants can then be used rather than a much larger implant with very different dimensions on the smaller breast.

Constricted or tubular breast can be very challenging and risky. The risk is most notable from a potential increase in vascular compromize after releasing the constricted tissues for expansion or NAC rotation. A “donut” style mastopexy may be beneficial for only small volume tubular breast but has very little benefit for any larger-volume breast. The tissues are often dense and require additional release to get the pedicle to rotate during a vertical or inverted T mastopexy so extra caution must be used to avoid any necrosis. Therefore, large pedunculated and constricted breast should be staged if both a mastopexy and implants are considered (Figure 17).

Figure 17.

Constricted or tubular breast treatment. Both patients shown above have “constricted / tubular” type breast with asymmetry. Constriction of the breast can compromize the breast blood supply and increase risk. Both were treated with a superomedial-central pedicle (SMC) mastopexy. However, the patient on top underwent simultaneous breast implant placement with mastopexy. Whereas the patient in the lower picture was treated in 2 stages because her constricted breast was much heavier and carried more risk. Both required excessive tissue to be removed particularly from the larger of the two breasts.

Lastly, extreme ptosis after massive weight loss (MWL) has its own challenges. Due to the poor quality of residual breast tissue, isolated mastopexies are often not enough to give a great and long-lasting result. Often these patients require removal of as much of the excess glandular tissue as possible to lighten the breast, as well as prevent a “waterfall” or “snoopy nose” deformity later when poor quality tissues slide off the implants placed under muscle. So, the goal in MWL breast surgery is frequently to remove as much stretched-out glandular tissue, as well as skin and replace the volume using total submuscular implants. Obviously, if the breast is extremely ptotic or the patient desires extremely large implants then the procedure may require staging (Figure 18).

Figure 18.

Severe breast ptosis treatment. Massive weight loss patients like the one shown above who lost 150 lbs., typically require excision of major excess breast tissue and replacement of excised tissue with a total submuscular implant to decrease risk of bottoming out. This will also improve appearance due to the increased implant to tissue ratio (i.e., more implant less natural breast). The key point is that reduction of the poor-quality native breast tissue with help prevent relapse of ptosis and waterfall-type deformity.

4.6 Nipple-areolar complex refinement/reconstruction

Nipple-areolar complex (NAC) refinement is a crucial component in breast reconstruction. An aesthetically pleasing NAC serves as a cornerstone for achieving an optimal outcome, and it must lie within the surgeon’s realm of expertize. Instances warranting NAC refinement span from unsatisfactory outcomes following previous breast reconstruction, NAC asymmetry, disproportionately enlarged NACs, and pronounced discoloration. The goal of refinement is to attain an NAC that embodies naturalness, symmetry, and proportionality.

For patients presenting with NAC irregularities, ranging from minor asymmetries to tubular breasts deformities, a repertoire of mastopexy designs can prove invaluable in restoring the NAC. In cases of minor asymmetries, a crescent lift permits the surgeon to address a vertical discrepancy between the NACs. In cases of tubular breasts with a protruding NAC, a Benelli or Donut mastopexy is beneficial in reducing the projection of the breast mound and concurrently flattening the NAC (Figure 19).

Figure 19.

NAC asymmetry. An array of mastopexy designs may be employed to rectify asymmetries between individual nipple-areolar complexes (NACs) and to harmonize disproportionate NACs.

After undergoing breast reconstruction, the nipple-areolar complex may lose its proportion and symmetry. An occurrence of NAC widening is particularly common when a Benelli/donut mastopexy has been performed as this technique can create excess tension along the incision margins. Opting for a vertical mastopexy, either independently or in conjunction with a horizontal component, offers the advantage of distributing tension evenly across the entire incision. This strategic approach not only reduces the risk of NAC widening but also effectively addresses the presence of prior scars (Figure 20).

Figure 20.

NAC refinement. The NAC may become disproportionate following breast reconstruction. Performing a vertical mastopexy with or without a horizontal component allows the surgeon to not only address the preexisting scars but also minimize NAC stretching.

A more recent stride in enhancing breast aesthetics post-reconstruction involves the innovative application of NAC tattooing. Prior breast surgeries can result in NAC distortion, nipple or NAC discoloration, and even nipple necrosis. Proficient tattoo artists possess the ability to emulate the NAC’s natural appearance, seamlessly melding it with the adjacent skin. This includes devising a tailored color palette for each patient and artfully imbuing the nipple with texture and dimension, yielding remarkably authentic results.

5. Conclusion

Aesthetic revision breast surgery or surgery for a variety of complex breast issues represents a transformative journey for both the patient and surgeon with the aim to restore the breast form. Through the interplay of meticulous planning, surgical expertize/technique, a deep understanding of each patient’s unique needs/desires, and artistic ability, the surgeon is able to recreate beauty while restoring the patient’s self-confidence. While the procedure can provide significant benefits, it is essential to consider the potential risks and have realistic expectations about the outcomes. Patients requiring revision breast surgery should research potential surgeons carefully and choose an experienced, surgeon who has a successful track record of performing revisional surgery.

Disclosure statement

The authors have nothing to disclose.