Revisions in Breast Augmentation

Transcription

1 Revisions in Breast Augmentation Editor s note: My thanks to the moderator, Neal Handel, MD (board-certified plastic surgeon and ASAPS member, Los Angeles, CA), and to panelists Barbara B. Hayden, MD (board-certified plastic surgeon and ASAPS member, Santa Monica, CA); William H. Jervis, MD (board-certified plastic surgeon and ASAPS member, Walnut Creek, CA); and Patrick G. Maxwell, MD (board-certified plastic surgeon and ASAPS member, Nashville, TN), for sharing their opinions and clinical experiences. Dr. Handel: Every plastic surgeon in practice encounters augmentation patients in need of revisionary surgery. This panel will discuss management of some of the common complications of breast augmentation that may require secondary surgery. The first case is that of a 34-year-old woman who Neal Handel, MD underwent augmentation with subpectoral silicone gel-filled implants. She received intraoperative Ancef and postoperative oral Keflex. Ten days after surgery, she noted erythema and a small amount of drainage from the left periareolar incision (Figure 1). Culture and sensitivity studies at that time revealed 1+ Staphylococcus aureus. Dr. William H. Jervis, MD Hayden, in your practice, do you routinely use prophylactic antibiotics in breast augmentation patients? How would you manage this case? Dr. Hayden: I do use antibiotics prophylactically, as I frequently use drains in the perioperative period. I continue antibiotics for at least 48 hours after drain removal. I would manage this case by first determining whether this is a superficial wound infection or a periprosthetic infection. The clinical exam will most likely define the extent of the problem. Focal tenderness around a limited wound would suggest a very localized problem. Induration, erythema, and tenderness around the device, along the dependent portion of the implant pocket, and along the inframammary fold would suggest a periprosthetic infection. This patient s photographs are suggestive of a localized infection, such as a stitch abscess. The diagnosis can be confirmed by wound exploration in a minor procedure room to see whether the local wound communicates with the implant pocket. If the problem seems localized to the superficial tissues, the patient may be treated with oral antibiotics and watched closely over the next 24 to 48 hours. The more extensive the erythema, induration, and tenderness, the more concern I have that the infection is or will become periprosthetic. I do not hesitate to put patients on intravenous antibiotics if I am unsure. If the wound is superficial and is improving with oral antibiotics, I continue the antibiotics for 7 Barbara B. Hayden, MD to 14 days. If the wound is superficial but has not significantly improved within 48 hours, I put the patient on intravenous antibiotics. If the wound is resistant to improvement with intravenous antibiotics and the infection appears periprosthetic, I consider implant removal early in order to minimize tissue injury and scarring. Patrick G. Maxwell, MD Dr. Handel: Dr. Maxwell, in cases of infection following breast augmentation, what criteria do you use to determine if and when explantation is necessary? Dr. Maxwell: I agree with Dr. Hayden. The key factor in this case is to determine whether this is a periprosthetic space infection or a wound infection. In cases of infection that cannot be controlled by intravenous antibiotics, one must explore and irrigate the pocket, replacing the implant or taking it out altogether. If a 7- to 10-day course of outpatient intravenous antibiotics does not control the infection, then I would remove the implant. A ESTHETIC S URGERY J OURNAL ~ MARCH/APRIL

2 Figure 1. Postoperative views of a 34-year-old woman 10 days after routine augmentation with subpectoral silicone gel implants. She received intraoperative Ancef and postoperative Keflex. She noted erythema and slight drainage from the left periareolar incision 10 days postoperatively. Dr. Handel: Dr. Jervis, in cases in which it is necessary to remove an infected implant, how do you determine when to reinsert the implant and how do you deal with the additional expenses incurred by secondary surgery? Dr. Jervis: I wait until all signs of inflammation have disappeared, which normally takes from 3 to 6 months after the initial removal of the implant. Fortunately, this problem is very rare. Other than a case that came from the East Coast last year (which cultured atypical Mycobacterium), I have not seen a periprosthetic infection since I started placing almost all implants retromuscularly in I generally would not charge a professional fee for one of my patients. We would, however, ask the patient to meet us halfway on the operating room expense in my own facility. Dr. Handel: What about anesthesia and the cost of the replacement implant? Dr. Jervis: The patient would pay for the implant, but I ve actually had one manufacturer replace an implant at no cost. We would expect the patient to pay for the anesthesiologist. Dr. Handel: Dr. Jervis, would you use parenteral or oral antibiotics on this patient? Dr. Jervis: You would need to perform a culture and sensitivity testing and start right away with either oral Cleocin or Chloramphenicol, understanding that there are risks with using either one. The appropriate sensitivities are more likely to occur with those antibiotics. At times, I place vancomycin into the wound itself and try to lavage it briskly. If the infection is periprosthetic and it communicates, I think you have the best chance of salvaging the implant by placing some antibiotic around it, particularly vancomycin, which has a 100% sensitivity to staphylococcus. The other thing to consider is the possibility of atypical mycobacterium. This takes 3 to 4 weeks to determine with a culture, which must be requested by the laboratory. It is possible that a patient would develop this type of infection and have it go undetected in the absence of such a culture. You can have a superinfection with staphylococcus. Atypical mycobacteria may be sensitive to amikacin sulfate around the implant or tetracycline by mouth. I have cultured atypical mycobacteria twice; this culture must be specifically requested. One instance was approximately 20 years ago. About 1 year ago, a patient who had surgery on the East Coast came in with redness and mild discomfort. These symptoms did not resolve with oral cephalosporins or ciprofloxacin, which was discontinued at 3 weeks after surgery on one side and 6 weeks after surgery on the other side. Atypical mycobacteria grew independently from each side. She was subsequently reimplanted 6 months later and has done well. Dr. Handel: Let us move on to case number 2. This is a 26-year-old woman who underwent bilateral breast augmentation in 1996 with submammary saline-filled implants placed through an inframammary incision. Immediately after surgery, the patient noticed symmastia. Her surgeon attempted a revision in 1998, at which time he placed internal tacking features and put in larger implants. However, the patient was not improved by the second operation (Figure 2). Dr. Maxwell, how would you evaluate and manage her at this point? Dr. Maxwell: I think it s pretty obvious from the photographs that the imprint of the original inframammary fold is visible in the inferomedial aspect of each breast. It s also clear that the inframammary fold was overdissected inferomedially as well as medially. In the initial attempt to correct the problem, larger or wider diameter implants were used, which further complicated the correction. 142 A ESTHETIC S URGERY J OURNAL ~ MARCH/APRIL 2000 Volume 20, Number 2

3 I think the best option at this point is to go back through the inframammary approach to create subpectoral pockets. The implant would then be separated medially on each side by the margin of the muscles. Tacking sutures would be necessary to re-create the original inframammary fold and presternal tissue. But because the implant is now subpectoral, these sutures should hold up. Dr. Handel: When you convert from the submammary to the subpectoral position, would you remove the scar tissue capsule lining the anterior surface of the muscle and the overlying breast tissue? Dr. Maxwell: The only reason to remove capsule or release capsule on the anterior muscle surface would be to allow expansion of that muscle or alleviate any deformity. I would remove only as much capsule as necessary. It doesn t look as though the capsule is constricting in any way, so there probably is no reason to remove any of it. In regard to the adherence in the problematic areas, if the implant is in the submuscular position or subpectoral position and is not impinging on the areas that are problematic, I would still leave the capsule and suture the anterior to posterior capsule. Dr. Handel: I have seen cases in which implants have spontaneously dislocated from the subpectoral to the submammary position. This occurs when the old scar tissue capsule persists as a potential space for many years after explantation. Have you encountered this problem? Dr. Maxwell: No, not if sutures are used approximating the anterior to posterior capsule. Dr. Handel: Dr. Jervis, do you advocate a single stage procedure as Dr. Maxwell describes? Dr. Jervis: I don t think you need a staged approach. One could conceivably salvage the implants and leave them in front of the muscle, performing an absolutely meticulous closure of the medial and inferior aspect, without going to an entirely new space. If you want to close off the space, you may have better success by doing a partial capsulectomy internally, using a large number of permanent woven sutures Ethibond sutures (ETHICON, Inc., Somerville, NJ) to close it off. Dr. Handel: Dr. Hayden, would you consider performing the repair and then inserting an adjustable prosthesis in a case such as this? Dr. Hayden: I think that is an option, but it would not be my preference. I have concern that the adjustable devices would offer little advantage for either the patient or the physician in this case. Adjustable devices seem to be most useful when one is attempting to correct asymmetries. I worry that a Figure 2. Postoperative views of a 26-year-old woman who underwent breast augmentation in 1996 with saline-filled implants inserted through an inframammary incision. The patient noted symmastia immediately after surgery. Her surgeon attempted revision in 1998, placing internal tacking sutures and inserting larger implants. She was not improved by the second operation and now seeks further treatment. The implants appear to be submammary. volume increase of greater than 50 to 75 cc may result in a stiff and rounded breast confined by a small pocket. In this patient, I am concerned about the suggestion to keep the same device and stay in the subglandular position. If one elevates the One could conceivably salvage the implants and leave them in front of the muscle, performing an absolutely meticulous closure of the medial and inferior aspect, without going to an entirely new space. William H. Jervis, MD Revisions in Breast Augmentation A ESTHETIC S URGERY J OURNAL ~ MARCH/APRIL

4 Figure 3. Postoperative views of a 37-year-old woman who underwent breast augmentation 10 years earlier. She developed capsular contracture and has had multiple capsulotomies, capsulectomies, and implant replacements. She currently has Mentor Siltex gel-filled implants in the submammary position. inframammary fold medially and tightens the pocket along the sternum, the original device just isn t going to fit without significant tension. I would expect that it would tear at the repair. I think it would be an even bigger mistake to put in a larger device. This woman already has a symmastia and significant distortion of her natural contour and inframammary fold. A subpectoral pocket may protect the medial repair and give greater definition and support to the cleavage. A smaller device will relieve pressure along the fold and allow the contour of the implant to stay within the contour of her existing breast. My first choice would be a smaller silicone gel-filled implant. If the patient has folds with a saline device, you can improve them with the gel-filled, but you will still have some rippling. Barbara B. Hayden, MD Dr. Maxwell: I would like to comment on the idea of leaving the implant in the same pocket using multiple meticulous sutures. The problem is that this is very thin presternal tissue. Dissecting tissue beneath the inframammary fold is a very difficult and tedious process because each stitch must be perfect. If the stitch is not deep enough, it will tear. If it s too deep, it will cause depressions. Even if you are successful initially, recurrence of the inframammary fold deformity is a possibility. Dr. Handel: The third case is that of a 37-year-old woman who had a breast augmentation 10 years earlier. She had problems with capsular contracture, necessitating multiple capsulotomies and capsulectomies, and currently has Mentor Siltex (Mentor Corp., Santa Barbara, CA) gel-filled implants in the submammary position (Figure 3). Although she is happy with her appearance when standing upright, when she leans forward, she has noticeable waviness and rippling. Dr. Hayden, what is your approach to patients with this problem? Dr. Hayden: You first need to determine the location of the waviness that is causing the patient the most distress. It is fortunate in this particular case that the rippling is in the upper inner quadrant of both breasts and not in the outer poles. Replacing the device in the submuscular pocket could alleviate this problem. Whether you are using saline or silicone, that extra degree of padding will provide some coverage in the upper inner quadrant. You ll still have folds, however, in the lower inner quadrant and outer poles of the breast, which are very hard to deal with. If the patient has folds with a saline device, you can improve them with the gel-filled, but you will still have some rippling. I do not believe that the gel devices have the same effect on tissues. I have been impressed with the extent of seroma formation seen with the Mentor device. This fluid might be used to our advantage in the patient with traction folds and thin tissue. In contrast, the McGhan Device (McGhan Medical, Santa Barbara, CA) demonstrates excellent tissue ingrowth, but in some cases 144 A ESTHETIC S URGERY J OURNAL ~ MARCH/APRIL 2000 Volume 20, Number 2

5 this may not be desired and adherence to the tissues may accentuate the folds. Dr. Handel: Dr. Maxwell, in patients with a thin overlying envelope of soft tissue, have you ever attempted overinflation of saline implants? Dr. Maxwell: No, this is a bad idea. Because of the location of these upper-pole rippling folds, this is a traction phenomenon. Despite the fullness of the implant, there would still be traction in the upper region. Overexpanding the saline implant will just re-create the problem and make it worse over time. Dr. Hayden: There is a tendency to want to use a larger device to deal with folds. Sometimes this will work. In effect, this approach is an attempt to create a degree of capsular contracture or tightening that may lessen folds and ripples. Wouldn t a more logical approach be to reduce the size of the pocket? This would create that firmness without risking more of the problems associated with the larger devices, such as progressive thinning of tissues over time, ptosis, and inadequate soft tissue coverage for the diameter of the larger device. Dr. Maxwell: I agree with Dr. Hayden. The upper-pole or traction ripples result from implant space disproportion big pocket, small implant. Decreasing the pocket size is a good solution. Dr. Handel: Dr. Jervis, in addition to seeing occasional patients with obvious wrinkling and waviness of the breast, we often encounter patients with easily palpable implants, particularly inferiorly and laterally. What treatment is indicated for these cases? Dr. Jervis: In the past, I have tried to oversew the tissue internally; this results in variable degrees of success. In 2 or 3 cases, I have placed 3 7- cm sheets of Alloderm (Lifecell Corp., The Woodlands, TX) inside the pocket. I sew the patches to the breast capsule with permanent sutures, allowing for revascularization. This is a very expensive option, however. For thin spots inferiorly, I have occasionally used posterior scar capsule flaps inferiorly based, flipped anteriorly, and sewn in place with Ethibond sutures. I do not recall this procedure having failed, but I cannot verify long-term results. Dr. Handel: The next case is that of a 31-year-old woman who had a routine subpectoral breast augmentation with Mentor smooth round saline implants. Her postoperative photographs 1 year after surgery reveal inferior displacement of both implants (Figure 4). Dr. Jervis, what treatment would you recommend? Dr. Jervis: I would perform a meticulous oversewing of the internal space. Most recently, I have done a partial capsulectomy in order to improve healing; this takes much longer to do than the original surgery, however probably an hour and a half per side. I carefully mark out the fold I want, transferring the external markings internally. I then insert a minimum of 20 to 30 sutures on each side, closing the space off in layers. I try to overcorrect a bit because, as Dr. Maxwell said, some stretching of the tissues will occur from the implant. Dr. Handel: When you perform this Figure 4. Postoperative views of a 31-year-old woman 1 year after routine subpectoral augmentation with Mentor smooth round saline-filled implants, inflated to 385 cc. Note the inferior displacement of the implants. type of capsuloplasty, do you have any tricks to ensure a smooth, round contour at the bottom of the breast? Dr. Jervis: You have to sit the patient upright and check the shape of her breasts as you go, looking externally. I ve performed this technique only with the patient under general anesthesia because it s hard to keep the tissues blocked for the long-term using local anesthesia. Dr. Hayden: Sometimes you can pick up on that capsule and see where the little bands are that attach the skin to the old inframammary fold. This works with breast cancer patients as well, when their inframammary fold has been overdissected during mastectomy. If you take the capsule, score it below that point on the anterior surface, and then tack it, pulling up on the posterior part of the capsule, you can actually re-cre- Revisions in Breast Augmentation A ESTHETIC S URGERY J OURNAL ~ MARCH/APRIL

6 ate this little sling without worrying about those suture indentations that Dr. Maxwell was talking about. Dr. Handel: If I understand you correctly, you are suggesting using the scar tissue capsule as an advancement flap. Dr. Hayden: Exactly. It s suturing from the low anterior flap to the high posterior scar capsule. This creates a nice sling. You do have to put a double row in, but you are not trying to get below the dermis to create the fold; you are actually using those little pre-existing ligaments in the old fold to help you do that. Dr. Handel: When a patient presents with an implant that appears too low, is it always because the surgical pocket was dissected excessively, or could it be because the implant has descended spontaneously over time? Dr. Hayden: You could argue that the implants have descended over time, but I would say that the burden is still on the surgeon to prove that it was not an overdissection of the pocket. It is possible that the inframammary fold was overdissected. But perhaps the medial inferior origin of the pectoralis major was not adequately released. Because her cleavage is still quite wide and her pectoralis major sits high, I can t help but wonder whether the muscle pushed it down and out. By releasing that muscle medially up to the nipple level so that the muscle band is not constantly pushing the implant down, you would get a better positioning of the device and less likelihood that the implant would then be massaged down over time. Dr. Handel: Dr. Maxwell, if an implant appears to be too low immediately after augmentation mammaplasty, are there conservative measures such as taping or under-wire support bras that are effective in readjusting the inframammary fold? Dr. Maxwell: The majority of breast augmentations that result in low implants represent surgical pocket overdissection. Those of us who have advocated evaluating the necessary width of the implants and lowering the folds accordingly are somewhat responsible for this. The anatomically shaped saline implants that are heavier at the bottom tend to stretch the skin, further exacerbating this problem. Folds frequently do need to be lowered but must be done carefully and not be overdissected. I have not found percutaneous suturing through the interior and posterior capsule to be effective, although I ve tried this approach and others may have had success with it. When the malpositioning is minimal, I advocate under-wire bras or taping. In correcting this particular patient s problem, I would suture the anterior to posterior capsule in The majority of breast augmentations that result in low implants represent surgical pocket overdissection. Patrick G. Maxwell, MD several places and then create a retroglandular pocket to the exact location of the fold. Dr. Handel: Would there be any advantages to using a textured implant rather than a smooth implant to prevent recurrence of this problem? Dr. Maxwell: Yes, but I think proper pocket dissection is more important. I would prefer gel over saline because there is less weight. Dr. Handel: The next patient is a 44- year-old woman who had a breast augmentation in 1984 with subpectoral silicone gel-filled implants. She had a good result and says that she had no problems for years, until she was injured at work; some heavy boxes fell, striking her in the chest. Over the course of the next several months, her breasts became firmer and progressively more distorted (Figure 5). Dr. Jervis, how would you manage this patient? Dr. Jervis: This patient s claim and description should be presented to the industrial carrier, and magnetic resonance imaging, a mammogram, or a sonogram should be requested to determine whether the implants are ruptured. Industrially related or not, the appropriate treatment must be administered. In cases of a leak or rupture, efforts should be made to remove the silicone, although the patient must be advised that it might not be possible to remove it all. Try to preserve the capsule as best you can because, in my opinion, it will frequently inhibit the future contraction process. Occasionally, with a very thick capsule, you may have to perform a partial or total capsulectomy. I would use a saline-filled implant for replacement if the tissues are thick enough to cover it. 146 A ESTHETIC S URGERY J OURNAL ~ MARCH/APRIL 2000 Volume 20, Number 2

7 Dr. Handel: Your inclination in cases of capsular contracture is to perform a capsulotomy rather than a capsulectomy? Dr. Jervis: A combination of the two. Frankly, I have not seen a Baker 3 or 4 contracture yet in any implant that I have inserted behind the muscle. I have never had to go back on a single one, and I have inserted all but 4 behind the muscle since However, I have seen 2 or 3 that I would reoperate on if the patient also felt that her breast was too hard. Dr. Handel: Dr. Hayden, does your approach differ from this? Dr. Hayden: First of all, I think a good case history is important in assessing the cause of capsules. Was there swelling? Was there any bruising? Was there periprosthetic bleeding after trauma? Could there be another explanation? Could the patient have oral disease or a urinary tract infection, or chronic infection elsewhere that keeps colonizing your device? If you think her implants might be ruptured but you want to save them and not intervene if they are intact, then magnetic resonance imaging is recommended. If you ve already made the decision to go in and revise these implants, then an ultrasound and a mammogram are mandatory. A physical examination in which the pinch test is done would also be revealing. If she has a lot of silicone in the wound and tissues, I recommend removing the debris because it will complicate the mammograms and subsequent clinical examinations for breast cancer. I would also take out the capsule if it s impregnated with little bits of silicone. A complete capsulectomy is usually unnecessary for subpectoral capsules. The posterior aspect of the capsule, adherent to the ribs, can be left alone. But sometimes a thick retropectoral capsule may require scoring or peeling in order for you to get an unrestricted relaxation and stretch of the pectoralis major muscles. Silicone granulomas, scar tissue, and other palpable nodules merit removal to maximize the sensitivity of breast cancer screening exams and mammograms. Dr. Handel: Dr. Maxwell, would you consider converting this patient to a submammary implant? Dr. Maxwell: The principle is to put the existing device or a new device in contact with virgin tissue. That can be accomplished either by total surgical capsulectomy or by site change. Total submuscular capsulectomy is not my first choice. If this patient has adequate soft tissue, I would move the location of the implant from the submuscular pocket to a retroglandular pocket, and I would probably switch to textured implants because of her history of capsular contracture. Dr. Hayden: Dr. Maxwell, doesn t she also have a tuberous breast shape, with a short distance from the inframammary fold to the nipple? One could correct this malformation and improve the aesthetic outcome by changing it to the subglandular position. I question whether a submuscular approach is really the best option, given the shape of her breasts. Dr. Maxwell: I agree. Placing the Figure 5. Postoperative views of a 44-year-old woman who had augmentation in 1984 with subpectoral silicone gel-filled implants that were inserted through a periareolar approach. She had a good result and no problems until she was injured at work (heavy boxes fell from a shelf and struck her in the chest). Over the next several months, her breasts became firmer and progressively more distorted. implant over the muscle would give her a better aesthetic result. Dr. Handel: Dr. Jervis, do you use breast massage routinely in your practice? Dr. Jervis: Yes, I do. I usually put in smooth, round implants under the muscle and have the patients start massaging 2 weeks after surgery. I continue massage for 6 weeks to 3 months. In my experience, once retropectoral implants become soft, they don t harden. Dr. Handel: There is contradictory evidence in the literature regarding the efficacy of breast massage to prevent contracture. Dr. Hayden, do you believe massage is a useful maneuver? Dr. Hayden: I think it depends on Revisions in Breast Augmentation A ESTHETIC S URGERY J OURNAL ~ MARCH/APRIL

8 the type of device you are using. With a smooth device, massage may make sense. With a textured device, I think it may in fact be detrimental. Dr. Handel: Dr. Maxwell, do you feel that breast trauma can precipitate or contribute to contracture? Dr. Maxwell: I certainly think it is possible. It seems a little unusual, however, that this patient would do very well for many years only to have equal trauma to both breasts and develop equal capsular contracture later. A seatbelt injury or some other kind of unilateral injury would be more frequently seen. But I do think that trauma can contribute to capsular contracture. Dr. Handel: Would you all agree that capsular contracture is the most common complication that we see in our breast augmentation patients? Dr. Hayden: I disagree with that statement. I think that these wrinkle and fold problems are actually becoming far more of a nemesis than contracture is. I think that the correct use of textured saline devices has lowered the incidence of contracture. Dr. Handel: How do the panelists explain the common phenomenon of seeing one implant that is soft and natural-feeling while the other is firm and contracted? Is this due to subclinical infection on one side or different dissection of the pocket? Dr. Hayden: Capsular contracture is most often seen after a systemic infection is cleared. By the time we see the patients, they don t even remember that they had a respiratory or urinary tract infection or an infected wisdom tooth that has been long resolved. The breast pain may have been transient. If a patient has a problem with her teeth, that should be taken care of before you can operate on her breast implants. Dr. Jervis: Some surgeons still place their patients on antibiotics before they go to the dentist. Dr. Hayden: I do this because of the data on other prosthetic devices. The orthopedists do it for their hip and knee replacements. Cardiac surgeons Receive ASJ Table of Contents by To receive the table of contents by when a new issue of ASJ is posted online, sign up through Mosby s Web site at Choose Notification. Simply type your address in the box and click the Subscribe button. recommend antibiotics for valve replacements and mitral valve prolapse. There are enough data to support the use of antibiotics in implant patients undergoing any surgery or procedure in a contaminated area. Why should we think breast implants are any different? Dr. Jervis: Does everyone here lavage the implant and space at the end of the procedure with an antibiotic such as gentamicin? Dr. Hayden: I don t do this routinely. There are times, however, when I will irrigate the pocket with sterile saline. I use nonpowdered gloves and the minimal-touch technique, but I do not use any bactericidal irrigant. Dr. Maxwell: I irrigate with saline to be certain that there is no bleeding and then irrigate with providone iodine. Dr. Handel: I would like to thank all the panelists for their insightful comments. Reprint orders: Mosby, Inc, Westline Industrial Drive, St Louis, MO ; phone (314) ; reprint no. 70/1/ doi: /maj Alternatively, you may send an message to majordomo@mosby.com. Leave the subject line blank and type the following as the body of your message: subscribeaesthetic_toc You will receive an to confirm that you have been added to the mailing list. 148 A ESTHETIC S URGERY J OURNAL ~ MARCH/APRIL 2000 Volume 20, Number 2