**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.
