**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-

#### **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.*

### *Revisions for Complications of Aesthetic Breast Surgery DOI: http://dx.doi.org/10.5772/intechopen.112915*

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

#### **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.*

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**).

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

#### **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.*

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**).

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**).

#### **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, subglandular 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


## **Table 3.**

*Baker grade of capsular contracture [23].*

resonance imaging (MRI), may be utilized to assess the extent of contracture and implant integrity.

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,

**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.*

#### *Revisions for Complications of Aesthetic Breast Surgery DOI: http://dx.doi.org/10.5772/intechopen.112915*

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**).

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,

#### **Figure 14.**

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

#### **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.*

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**).

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 breastconserving 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. Highcohesive 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**).

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

#### **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.*

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**).

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

*Revisions for Complications of Aesthetic Breast Surgery DOI: http://dx.doi.org/10.5772/intechopen.112915*

#### **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.*

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**).

#### **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**).

After undergoing breast reconstruction, the nipple-areolar complex may lose its proportion and symmetry. An occurrence of NAC widening is particularly common

#### **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.*

#### **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.*

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 *Revisions for Complications of Aesthetic Breast Surgery DOI: http://dx.doi.org/10.5772/intechopen.112915*

#### **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.*

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**).

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.
