**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 subglandular 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**).


#### **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 reapproximated 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**).

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

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

#### **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.*

#### **Figure 4.**

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

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**).

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].

In regard to implant pocket selection, the authors routinely select a total submuscular plane. The total submuscular plane preserves the blood supply to the

#### **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.*

#### **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.*

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.
