 |
Advanced Art of Cosmetic Surgery Thomas M. DeWire, Sr., MD, FACS Specializing in Cosmetic Plastic Surgery |
Body Contouring |
|
| Breast Augmentation Revision Surgery | |
| Correction of Implant Displacement with Implant Bottoming Out-2 |
| Implant Displacement with Bottoming-Out: Case 2 |
| Case
2:
A 40
year old woman traveled from PA for
correction of recurrent and
severe Bottoming-Out of the left breast,
grade III capsule contracture of the right breast and unnatural breast
shape. The original augmentation used smooth saline implants, via crease incisions, 2 years earlier. She had two failed revision surgery attempts to correct Bottoming--Out and lateral implant displacement with rapid recurrence of the severe Bottoming-Out within six weeks of each revision surgery. Very thin, and with minimal breast tissue, this patient was not an ideal breast implant augmentation candidate. Significant chest wall asymmetry is also seen in this patient, with flaring of the lower ribs, especially on the lower left side.
|
 |
 |
This patient is seen 9 months after bilateral replacement of implants, release of capsule contractures and tailoring of pockets to correct breast shape and fold levels. At the time of repair, upper chest Symmastia was discovered and repaired by closure of the sternal aspect of the upper left pocket. Of great importance in preventing a recurrence of Bottoming-Out after repair, the upper pocket on each side was opened to create an oversized pocket. This maneuver prevents the downward pressure on the repair as post-op swelling builds in implant pockets as a part of the normal healing process. The lower pole and outer aspect of the left pocket were repaired by preserving excess capsule scar along the bottom, rolling it to add strength, and sewing it closed with permanent soft suture material. Despite the repair of the upper area of Symmastia (kissing pockets) at the time of the revision, this patient later developed more Symmastia over the mid-part of the breast bone as a consequence of the original surgical attempt to create "better cleavage" in a thin patient by releasing the edge of chest muscles along the breast bone. That maneuver led to the need for a second minor procedure to correct the Symmastia. The photos shown here are the final result after all repairs. | |||||||||||
 |
 |
|||||||||||||
 |
 |
|||||||||||||
 |
 |
|||||||||||||
|
|
||||||||||||||
| Case 2 Problems | Analysis of Cause | Correction |
| Bottoming Out | Initial placement approach caused loss of lower pole support as muscle fascia was cut to place the implants in the submuscular plane. This allowed later stretching of the lower pole skin, thus allowing the implant to displace downward, or Bottom-Out. Partial submuscular coverage of implants allows the contraction of the pectoral muscles lying over only the upper pole of the implants to displace them downward strongly, and in many cases stretches the lower pole skin, leading to an element of Bottoming-Out, with riding up of the crease incision onto the breasts. When severe, as in this case, repair is necessary to re-establish a natural and pleasing breast shape. | Release capsule contractures and then establish widely patent implant pockets, followed by reconstitution of the lower folds by permanent suture repair. Avoid by placing implants in a completely submuscular plane to preserve internal implant support. |
|
Prevention |
||
| Whenever possible, place implants in a completely submuscular pocket to allow for much stronger muscle element support of implants, and resistance to implant migration or downward displacement. | ||
| Failed Correction Attempts | Analysis and recognition of the cause of aesthetic problems is key, followed by a concise plan to repair each element of the problem. The key oversight in the earlier repair attempts was the failure to recognize the contribution of the relative capsule contracture to the stress on the repair site, causing it to open again, allowing recurrent Bottoming-Out. | Release and remove scar tissue to allow a large implant pocket to be established, and then use post-op massage techniques to prevent recurrent capsule formation, as well as downward displacement tendency in the area of the pocket repair, which remains the weakest area of an otherwise intact tight pocket. |
| Symmastia | Symmastia describes the phenomenon where the breast implants cross the breast bone to touch over the midline of the chest where the cleavage area would normally be seen. Attempts to "increase cleavage" by releasing the medial origins of the pectoralis muscles should not be done, as that maneuver has a significant risk of causing an abnormal appearance of the sternal region, if not frank migration of the implants over the breast bone. |
Repair and tailor breast implant pockets to constrain the implants lateral to the cleavage area over the breastbone. See: Symmastia Correction Page
|
| Capsule Contracture | Capsule
contracture is the result of inflammatory
scarring around a breast implant, or
any foreign material implanted in the body, and
seems most
likely caused by transient bacterial contamination of
the implant, presumably at the time of placement, and likely from
bacteria that live within the ducts of the breast tissue, or
on the skin..
|
Release or removal of scar around the implants and maintenance of an oversized pocket to help prevent contractile scarring. |
| Back to Augmentation Revision Page |
| Maps to Office | Thomas M. DeWire, Sr., MD, FACS | E-Mail Dr DeWire |
| Advanced Art of Cosmetic Surgery | ||
| 3974 Springfield Road | ||
| Glen Allen (Richmond), VA 23060 | ||
| 804-290-0200 |
 |
 |
| Terms of Use |
| ©Copyright 1997-2007 Advanced Art of Cosmetic Surgery: Thomas M. DeWire, Sr, MD, FACS Revised October 29, 2007 04:07:30 PM |