Controversy regarding the safety of silicone gelfilled

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1 Featured Operative Technique The Neopectoral Pocket in Revisionary reast Surgery G. Patrick Maxwell, MD; and Allen Gabriel, MD ontroversy regarding the safety of silicone gelfilled breast implants, which were usually placed in a subglandular pocket, resulted in a 1992 moratorium on their use for aesthetic breast augmentation. This forced American surgeons to use saline implants, which were placed under the muscle, thereby gaining extra tissue coverage to conceal the untoward contour irregularities of these implants. 1-3 Revisionary (secondary or tertiary) surgeries are often performed for late complications of breast augmentation, such as implant extrusion, gel bleed, rupture with extravasation of gel, saline implant deflation, capsular contracture, palpability, rippling, double bubble, Snoopy breast, symmastia, and implant malposition. 2 In the past, when most breasts were augmented with silicone gel-filled implants placed in a subglandular pocket, revisionary surgeries for capsular contracture were generally performed with a total capsulectomy, removal of the implant from the subglandular plane, and placement of a new implant in the submuscular position. 2 This is a fairly simple procedure, involving a change in implant placement from over the muscle to under the muscle. More recently, it has become necessary to perform revisionary surgery on volume-depleted breasts as a result of large saline implants that were placed under the muscle. Rarely do physicians see patients for revisionary surgery with existing submuscular saline implants that have adequate superficial soft tissue. Therefore, maintaining the bulk of the pectoralis muscle over the implant is desired. The implant site change procedure that we have developed creates a new submuscular plane that incorporates the use of the existing capsule. The new plane is termed Increasing numbers of patients are presenting with volume-depleted breasts as a result of large saline implants that were placed under the pectoral muscle. To treat this problem, the authors introduce a revisionary surgery technique, called the neopectoral pocket, designed for patients with subpectoral implants. This technique is useful for the management of late breast augmentation complications, such as capsular contracture and implant malposition, including double bubble breast deformity, Snoopy breast, and symmastia. The creation of the neopectoral pocket maintains muscle coverage over the implant, allowing control of pocket size while minimizing trauma. (Aesthetic Surg J 2008;28: ) the neopectoral pocket, defined as the pocket deep to the pectoralis major but superficial to the anterior capsule, which is left intact. Removing the capsule would not only cause more tissue damage, but also result in the creation of a larger space than the original pocket, necessitating the use of larger than desired implants. The advantages of creating a new pocket (instead of performing a total capsulectomy) are less trauma, ease of dissection, precise dissection with regard to the inframammary fold (IMF) for a double-bubble deformity or inferior implant displacement, and precise medial and lateral dissection for correcting symmastia or lateral displacement, respectively. Further, this procedure can effectively treat capsular contracture by creating a new pocket when using any textured implant (round or anatomic) for vascularized attachment of the textured surface. The accurate development of this pocket is even more important when placing an anatomic implant; using this method, the pocket will be snug to accommodate the implant. This is critical for a good outcome, because placement of an anatomic implant into too large a pocket will lead to decreased adherence and implant rotation. In the past, when patients presented with capsular contracture or other implant-related complications, the surgeon had limited options. The site change principle, described in the mid-1990s, 4 led to the idea of total or partial capsulectomy with conversion to a different pocket with or without dual plane conversion. 4 7 The addition of the neopectoral pocket technique to the armamentarium of plastic surgeons treating secondary implant-related complications will provide increased options, simplifying the management of complex problems (Table). The authors are from the Department of Plastic Surgery, Loma Linda University Medical enter, Loma Linda, A. Dr. Maxwell is linical Professor of Surgery and Dr. Gabriel is Director of linical Research. Aesthetic Surgery Journal TEHNIQUE We prefer all procedures to be under general anesthesia and approach all revisionary surgeries through an IMF Volume 28 Number 4 July/August

apsular contracture Revision from round to anatomical implant ontraindications (relative) Extensive subpectoral calcified capsule Inability to create space Old capsule Incision Illustrations by

incision, unless a concurrent mastopexy is also needed (Figure 1). The incision is injected with 1% lidocaine with epinephrine and carried to the level of the capsule.

2 Table. Indications and contraindications Indications Double bubble Snoopy breast Double fold Inferior displacement of inframammary fold Symmastia Lateral displacement of implant Pocket irregularities apsular contracture Revision from round to anatomical implant ontraindications (relative) Extensive subpectoral calcified capsule Inability to create space Old capsule Incision Illustrations by William M. Winn, Atlanta, GA Figure 1. All revisionary surgeries are approached through an inframammary fold incision unless a concurrent mastopexy is needed. incision, unless a concurrent mastopexy is also needed (Figure 1). The incision is injected with 1% lidocaine with epinephrine and carried to the level of the capsule. Dissection and Management A supracapsular plane is initiated immediately superficial to the anterior capsule until the pectoralis muscle edge is identified (Figure 2). It is easier to initiate this plane with the implant in place (Figure 3). Taut caudal Initiation of neopectoral pocket Figure 2. After the skin incision has been made, dissection begins with an electrocautery, in a supracapsular plane, initiated immediately superficial to the anterior capsule until the pectoralis muscle edge is identified. Developing neopectoral pocket Anterior surface of existing capsule Inferior margin of capsule Implant Muscle Pectoralis m. Muscle Implant Figure 3. Once the edge of the pectoralis major is identified, a retractor is placed to ease the separation between the pectoralis major and the underlying anterior capsule. It is easier to initiate this plane with the implant in place. retraction of the anterior capsule with retractor elevation of the overlying pectoral muscle (when the implant is removed) facilitates the dissection, which is usually performed with electrocoagulation cautery (Figure 4). At this point, it should be clear whether or not the capsule can be used for creation of the neopectoral pocket (Figure 5, A). alcifications and level of thickness can be palpated and visualized. If the capsule is calcified or prob- 464 Volume 28 Number 4 July/August 2008 Aesthetic Surgery Journal

anterior capsule with retractor elevation of the overlying pectoral muscle facilitates it.

Neopectoral pocket opened Anterior existing capsule Old pocket Posterior existing capsule Obliteration

3 Implant removed Figure 4. When satisfactory dissection of the neopectoral pocket is achieved, the implant is removed through an incision into the anterior capsule. Following implant removal, if additional dissection is necessary, taut caudal retraction of the anterior capsule with retractor elevation of the overlying pectoral muscle facilitates it. A Pectoralis major m. Neopectoral pocket opened Anterior existing capsule Old pocket Posterior existing capsule Obliteration of old capsular space closed Old capsule space obliterated New implant in neopectoral pocket Figure 5. A and, The capsule is examined and the old pocket is sutured using interrupted silk or Vicryl sutures., The drain and implant are placed, and the incision is closed. Neopectoral Pocket in reast Surgery Volume 28 Number 4 July/August

4 A Figure 6. A,, Preoperative views of a 49-year-old woman with marked double-bubble breast deformity., D, Postoperative views 13 months following a single operation using the neopectoral pocket with non form stable textured gel implants. A D D Figure 7. A,, Preoperative views of a 46-year-old woman with marked capsular contracture and implant displacement., D, Postoperative views 15 months following augmentation mastopexy utilizing the neopectoral pocket with form stable, highly cohesive gel anatomic implants. 466 Volume 28 Number 4 July/August 2008 Aesthetic Surgery Journal

5 lematic, or if there is heavy silicone leakage into the pocket, the decision would be to excise it. If the capsule is simply encapsulated and tight, and does not feel calcified, then leaving the capsule would not cause a problem. In our large series of patients, we have documented that the capsule may be left, but that the capsular space must be obliterated. If the capsular space is not obliterated, the tissue will be too loose; there will be two layers of loose tissue, resulting in the tissue giving way from the chest. There are different ways to obliterate the space. In the past, we have used tetracycline, sclerosing agents, and different tissue glues; however, any of these may contaminate the new pocket and cause capsular contracture. What we have found to work best is simply suturing the old pocket with 4 to 5 sutures of 2-0 Vicryl (Figure 5, ). Neopectoral Pocket We visualize and complete the dissection of the neopectoral pocket. At times, there are patients with tissues so thin and capsules so friable that it would be difficult to use the anterior capsule. In these patients, we have tried using the posterior capsule, but that is a very difficult dissection. Taking the capsule of the anterior surface of the ribs can be done in some instances, but not consistently. In some challenging cases, in patients with thin tissues, we have successfully used acellular dermal matrices to enhance thickness and volume. Sizers are then placed, and the patient is placed in a 90 position and contour and pocket irregularities are addressed. Following the completion of both sides, the patient is again placed in a 90 position and the final artistic touches are completed (Figure 5, ). We always place 10 French Jackson-Pratt drains (ardinal Health, Dublin, OH) in patients who undergo revisionary breast surgery. ONLUSION The neopectoral pocket is a new type of implant site change operation. It addresses many of the problems seen in patients with subpectoral saline implants who request revisionary aesthetic breast surgery (Figures 6 and 7). This procedure allows for continued coverage of the implant by the pectoralis muscle, which conceals any implant related contour deformities that may be visible through attenuated overlying breast tissues. reation of a neopocket, as opposed to performing capsulectomy, minimizes trauma while optimizing control of pocket dimensions and location. DISLOSURES The authors have no disclosures with respect to this article. REFERENES 1. Maxwell GP, aker M. Augmentation mammaplsty: General considerations. In: Spear SL, Willey S, Robb GL, Hammond D, Nahabedian MY, eds. Surgery of the breast: Principles and art, 2nd ed. Philadelphia, PA: Lippincott-Raven Publishers; 2006: Handel N. Managing complications of augmentaion mammaplasty. In: Spear SL, Willey S, Robb GL, Hammond D, Nahabedian MY, eds. Surgery of the breast: Principles and art, 2nd ed. Philadelphia, PA: Lippincott-Raven Publishers; 2006: arbato, Pena M, Triana, Zambrano MA. Augmentation mammoplasty using the retrofascia approach. Aesthetic Plast Surg 2004;28: Maxwell GP, Tebbetts J, Hester TR. Site change in breast surgery. Presented at: American Association of Plastic Surgeons, St. Louis, MO; Hester Jr TR, Tebbetts J, Maxwell GP. The polyurethane-covered mammary prosthesis: Facts and fiction (II): A look back and a peek ahead. lin Plast Surg 2001;28: Spear SL, Ganz J. orrection of capsular contracture after augmentation mammaplasty by conversion to the subpectoral or dual-plane position. In: Spear SL, Willey S, Robb GL, Hammond D, Nahabedian MY, eds. Surgery of the breast: Principles and art, 2nd ed. Philadelphia, PA: Lippincott-Raven Publishers; 2006: Heden P. reast augmentation with anatomic, high cohesiveness silicone gel implants. In: Spear SL, Willey S, Robb GL, Hammond D, Nahabedian MY, eds. Surgery of the breast: Principles and art, 2nd ed. Philadelphia, PA: Lippincott-Raven Publishers; 2006: Accepted for publication April 2, Reprint requests: G. Patrick Maxwell, MD, 2021 hurch Street, Suite 806, Nashville, TN maxwellsmart@npsurg.com. opyright 2008 by The American Society for Aesthetic Plastic Surgery, Inc X/$34.00 doi: /j.asj Neopectoral Pocket in reast Surgery Volume 28 Number 4 July/August

Tackling challenging revision breast augmentation cases

the BREAST Careful preoperative consultations can reduce the need for revision breast surgery. Second Time Around Tackling challenging revision breast augmentation cases By Adam D. Schaffner, MD, FACS