BREAST

Surgical Correction of Breast Animation

Deformity with Implant Pocket Conversion
to a Prepectoral Plane
Michael C. Holland, M.D.
Rachel Lentz, M.D.
Hani Sbitany, M.D.
San Francisco, Calif.;
and New York, N.Y.
Background: Animation deformity is an undesirable outcome of subpectoral
breast reconstruction that results in abnormal breast contraction with activ-
ity, breast pain, and increased implant visibility. Surgical correction requires
implant removal and conversion of the reconstruction to a prepectoral plane.
The authors present their institutional experience with their preferred surgical
technique to treat this challenging problem and outline solutions for increased
success in these patients.
Methods: A retrospective review was performed of all patients undergoing con-
version of their subpectoral breast reconstruction to a prepectoral plane at the
authors’ institution. Patient demographics and surgical details were analyzed,
and postoperative outcomes and morbidity were assessed. The effects of chang-
ing operative strategies on enhanced success are also reported.
Results: A total of 80 breast conversions were performed over a 2.5-year pe-
riod. All patients demonstrated resolution of animation deformity at a mean
follow-up of 15.2 months. Two reconstructions (2.5 percent) required an un-
planned return to the operating room, and 11 reconstructions (13.8 percent)
were treated for infection. Preconversion fat grafting and the use of acellular
dermal matrix were both associated with a reduced incidence of postoperative
asymmetry and capsular contracture (p < 0.05). There were no reconstructive
failures associated with conversion to a prepectoral pocket.
Conclusions: Treatment of animation deformity in the reconstructed patient
can be safely performed by surgical conversion to a prepectoral plane. The
use of acellular dermal matrix, and preconversion fat grafting, in appropriate
patients can improve results. The authors promote this operative algorithm
for all reconstructive patients experiencing symptomatic animation deformity
with subpectoral breast reconstruction.  (Plast. Reconstr. Surg. 145: 632, 2020.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

F
or years, the most commonly performed
technique for prosthetic breast reconstruc-
tion has been submuscular, with elevation
of the pectoralis major muscle for partial or
complete implant coverage. This carries the ben-
efits of a reproducible outcome, with low rates of
infection and capsular contracture.1 However, a
consistent consequence of subpectoral or dual-
plane breast reconstruction is the tendency for
From the Division of Plastic and Reconstructive Surgery, De-
partment of Surgery, University of California, San Francis-
co; and the Division of Plastic and Reconstructive Surgery,
Department of Surgery, Mount Sinai Medical Center.
Received for publication January 31, 2019; accepted May 31,
2019.
Copyright © 2019 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000006590
the entire reconstructed breast to move with pec-
toralis muscle activation or contraction. This so-
called animation deformity can range in severity
from subclinical motion barely perceptible to the
patient, to drastic routine displacement of the
breast associated with pain, increased implant vis-
ibility, implant ripping, and a significant negative
impact on the patient’s quality of life (Fig. 1).2
Disclosure: Dr. Sbitany is a consultant for Aller-
gan, Inc. He received no compensation or support
for this study. The remaining authors have no disclo-
sures related to the content of this article.
Related digital media are available in the full-text
version of the article on www.PRSJournal.com.

632 www.PRSJournal.com
Volume 145, Number 3 • Correction of Breast Animation Deformity
Fig. 1. A 48-year-old woman with a 9-year history of bilateral
submuscular prosthetic breast reconstruction, shown with
symptomatic (painful) animation deformity on pectoralis major
muscle contraction; the typical distortion of the overlying breast
skin is seen on animation.
Such animation deformity occurs because the
elevated pectoralis major muscle, as it sits around
the prosthesis, adheres directly to the overlying
mastectomy skin flaps. Thus, when the muscle con-
tracts, it displaces the entire skin envelope above
with it, in addition to the underlying implant.
In patients with animation deformity after
breast augmentation, surgical correction has
been achieved by removing the breast implant
and mobilizing and resuspending the pectora-
lis muscle back to the chest wall, thus creating a
new subcutaneous plane for breast implant place-
ment.3 Until recently, there has been hesitation
to attempt this surgical approach in breast recon-
struction patients, as the lack of subcutaneous
tissue in skin flaps after mastectomy creates the
unique challenge of providing reduced soft-tissue
coverage of a breast implant moved to the prepec-
toral plane.
Recently, there has been a resurgence in the
rates of primary prepectoral breast reconstruc-
tion, with multiple series showing that prepec-
toral breast implant placement can be performed
safely.4,5 This resurgence has been assisted by
refinements in fat grafting and acellular dermal
matrix use for soft-tissue support.6 One of the
major benefits of these primary prepectoral breast
reconstruction techniques is the complete avoid-
ance of animation deformity, as the pectoralis
major muscle is separated from the mastectomy
skin by the intervening implant. Furthermore, the
pectoralis major muscle remains undisturbed and
thus patients experience no alteration in upper
extremity strength or range of motion.
Two recent studies have shown promising
results in surgical treatment of animation defor-
mity in the reconstruction patient. However, these
are either small clinical series7 or they fail to assess
predictors of success or result in unwanted out-
comes in their patients undergoing this revision
procedure.8 We aim to review our institutional
experience of operative correction for animation
deformity in reconstruction patients, and high-
light the evolution of our technique to obtain
optimal results in this heterogeneous population.
PATIENTS AND METHODS
A retrospective chart review was performed to
identify all patients undergoing conversion of their
subpectoral breast reconstruction to the prepec-
toral plane—specifically, to treat animation defor-
mity—between February of 2015 and October of
2018 at the University of California, San Francisco
Medical Center. All cases were performed by the
senior author (H.S.). Identified patients included
those who presented with complaints or symp-
toms of animation deformity, such as bothersome
and uncontrollable breast movement, pain, and
visibility of their breast prosthesis with pectoralis
muscle activation (Fig.  2). In addition, capsular
contracture and asymmetry were also seen in many
of these patients. Although there exists overlap
between patients with capsular contracture and
animation, patients included in this series were
only included if it was felt their complaints were
from unwanted implant movement with pectoralis
activation and not contracture alone. All patients
underwent removal of their existing implant, sepa-
ration of the pectoralis major muscle from the
overlying skin flap, resuspension of the muscle
directly to the chest wall, and placement of a new
prepectoral silicone implant.
Patients with prior autologous reconstruction,
who had not yet completed primary reconstruc-
tion, or without prior mastectomy (augmentation
mammoplasty patients) were excluded for the
purposes of this study. Patient preoperative demo-
graphics and medical comorbidities were reviewed
and recorded, as were perioperative details and
postoperative outcomes and morbidity. These
were obtained from a rigorous review of all clinic
notes and operative reports. All patients were
assessed both preoperatively and postoperatively
with in-person clinic evaluations by the senior sur-
geon, who ultimately determined the presence
or absence, and severity, of the various clinical
endpoints. Infection was defined by any clinical
suspicion for infection requiring continuation,
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 Plastic and Reconstructive Surgery • March 2020
Fig. 2. A 38-year-old woman with a 6-year history of bilateral submuscular prosthetic breast reconstruction, shown at rest (left) and
with animation of her pectoralis major muscle over the implants (center). The patient subsequently underwent bilateral conversion
to a prepectoral pocket, and is shown 1 year postoperatively (right), with inability to animate her reconstructed breasts.
changing, or initiation of antibiotics. Categorical
variables were analyzed with Fisher’s exact test
and continuous variables were compared with a
two-tailed t test, with values of p < 0.05 being inter-
preted as significant. Statistical analysis was per-
formed with IBM SPSS Version 23.0 (IBM Corp.,
Armonk, N.Y.).
Preferred Technique
Preoperative Patient Selection and Consent
Patients with submuscular breast reconstruc-
tion who present to the senior surgeon (H.S.)
complaining of discomfort, pain, or movement of
their breast with pectoralis activation may be can-
didates for conversion to the prepectoral plane.
We do not define a minimum amount of move-
ment or degree of pain to be requisite for surgery;
however, patients must exhibit clinically evident
animation deformity. Patients should have enough
overlying subcutaneous tissue to both mask the
contour of the eventual prepectoral implant
and serve as a durable layer of vascularized tis-
sue between the outside world and the implant.
Patients with at least 1 cm of subcutaneous tissue
on “pinch test” are ideal candidates for immedi-
ate surgical conversion, whereas patients with
less than 1 cm of subcutaneous tissue may benefit
from preoperative fat grafting in a staged fashion.
If no donor sites are available for fat grafting in
patients with thin mastectomy flaps, consideration
is given to not performing the conversion opera-
tion. Patients with extremely thin, attenuated skin
flaps should only be considered if the stretched
and excess skin is able to be excised during the
conversion procedure.
If unilateral animation exists in a bilateral
reconstruction, consideration should be given
to preemptively convert the nonaffected side for
634
symmetry. If animation deformity exists in a uni-
lateral reconstruction, an symmetry procedure
such as augmentation mammaplasty, reduction
mammaplasty, or mastopexy may be considered to
match the reconstructed side. As animation defor-
mity may be a debilitating complication of breast
reconstruction, we do not have any absolute con-
traindications for surgery, although smoking ces-
sation and improvement of poorly controlled
diabetes or other medical comorbidities must
occur before this elective procedure.
Intraoperative Technique
The patient’s prior submuscular reconstruc-
tion incision is typically used as the skin incision
for this procedure. In nipple-sparing patients,
this is typically a superior periareolar or inframa-
mmary fold incision. In patients without nipple
preservation, the transverse breast scar is used.
The inferior border of the pectoralis muscle
is identified and incised, to gain access to the
preexisting implant and capsule, both of which
are removed. It is our practice to perform a full
capsulectomy when the existing acellular dermal
matrix was easily removable, as long as there was
healthy overlying tissue. This helps remove tis-
sue that is often constricting and inhibiting the
new breast shape. In cases where acellular dermal
matrix removal is deemed unsafe because of thin
overlying skin, it is left in place and scored to assist
with recontouring. The plane between the pecto-
ralis major and the overlying subcutaneous tissue
is then developed, using low electrocautery and
sharp dissection. This is carried superiorly, medi-
ally, and laterally within the borders of the desired
new reconstructive footprint, to free the pectora-
lis muscle from the overlying tissue, and to cre-
ate a prepectoral pocket (Fig. 3). When free and
Volume 145, Number 3 • Correction of Breast Animation Deformity
Fig. 3. Surgical creation of a prepectoral pocket, by separat-
ing mastectomy skin from underlying pectoralis major muscle,
before removal of submuscular implant.
mobilized, the pectoralis major muscle is placed
on gentle traction and sutured to the chest wall
soft tissue in its original anatomical location using
interrupted 2-0 polydioxanone suture (Ethicon,
Inc., Somerville, N.J.) in a figure-of-eight configu-
ration. The breast pocket is irrigated and checked
for hemostasis followed by irrigation with a povi-
done-iodine–containing solution.
An implant sizer is placed in the breast pocket
to estimate new implant size. Cohesive gel implants
are preferable, to reduce rippling potential. The
new soft-tissue envelope around the implant is sup-
ported with biological mesh, which is performed
by completely covering the anterior surface and
small amount of the posterior/inferior surface
and securing it with 3-0 Vicryl sutures (Ethicon).
The most commonly used size of human acellular
dermal matrix to achieve this is a 16 × 20-cm piece
of mesh. The implant is placed into the pocket
using no-touch technique but not sutured into
place. One drain is typically placed into the breast
pocket to prevent the accumulation of fluid that
may otherwise prevent incorporation of the acel-
lular dermal matrix and to reduce seroma and
infection rates, and the skin is closed in multiple
layers. Sterile dressings are applied, and a soft sur-
gical bra is placed for support.
Postoperative Care
Patients are routinely given oral antibiotics
covering Gram-positive organisms for 7 days post-
operatively. Drains are kept in until the output
reaches less than 20 to 30 cc/day of output per
drain, on average 2 weeks after surgery, to allow
for proper acellular dermal matrix incorporation
to the surrounding tissue.
RESULTS
A total of 80 breasts underwent subpectoral-
to-prepectoral conversion, in 45 patients, between
February of 2015 and October of 2018, for treat-
ment of animation deformity. Thirty-five patients
(77.8 percent) underwent bilateral conversion in
70 breasts. Mean age at the time of revision was 50.6
years, and patients were a mean 4.65 years (range,
0.2 to 18.7 years) following most the recent sub-
pectoral implant placement. Twenty-seven breasts
(33.8 percent) were initially reconstructed at an
outside institution, and 58.8 percent of breasts
had undergone at least three prior operations.
At the time of subpectoral-to-prepectoral con-
version, three patients (3.8 percent) were cur-
rent tobacco smokers and 11.3 percent reported
active marijuana use. Diabetes was present in two
patients (2.5 percent), and the average body mass
index was 25.99 kg/m2. There were 10 irradiated
breasts (12.5 percent) undergoing conversion in
this series. Pertinent patient characteristics are
summarized in Table 1.
Fifty-one breast conversions (63.8 percent)
were performed in patients with a prior nipple-
sparing mastectomy. The most common incisions
used for conversion were superior periareolar
(51.3 percent), transverse (28.8 percent), and
inframammary (17.5 percent). Average new
implant size was 588.5 cc (range, 220 to 770 cc)
and average difference between new implant and
prior implant was an increase in size of 76.2 cc
(range, −125 to 295 cc). Acellular dermal matrix
was used in 65 revisions (81.3 percent) (AlloDerm;
Allergan, Inc., Irvine, Calif.).
Additional procedures performed at the time
of conversion included excision of excess mastec-
tomy skin for improved contour in 71.3 percent
of cases, contralateral symmetry procedures in 6.3
percent of conversions, and gynecologic surgery in
5.0 percent of revisions (four cases). The majority
of patients (82.5 percent) were discharged on the
day of surgery, with the remainder (17.5 percent)
leaving the hospital after 1 night of observation.
Postoperative antibiotics were prescribed on dis-
charge for 48 patients (60.0 percent). Pertinent
surgery details are summarized in Table 2.
For those patients undergoing conversion,
median follow-up was 15.2 months (range, 1.5
to 46.5 months). An unplanned return to the
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 Plastic and Reconstructive Surgery • March 2020

Table 1.  Patient Demographics and Medical Table 2.  Perioperative Surgical Details for Patients
Characteristics for Patients Undergoing Conversion Undergoing Conversion to a Prepectoral Pocket
to Prepectoral Pocket
Surgical Detail Value (%)
Characteristic Value (%) Total revisions 80 (100)
Total no. of patients 45 (100.00) Admission days
Total no. of breasts 80 (100.00)  0 66 (82.50)
Laterality  1 14 (17.50)
 Left 38 (47.50) Incision
 Right 42 (52.50)  Superior areolar 41 (51.25)
 Unilateral 10 (12.50)  Transverse 23 (28.75)
 Bilateral 70 (87.50)  IMF 14 (17.50)
Mean age at revision ± SD, yr 50.62 ± 9.55  New radial 1 (1.25)
Race  Vertical 1 (1.25)
 Caucasian 59 (73.75) Implant
 Other 16 (20.00)  Silicone 80 (100.00)
 Asian 3 (3.75)  Smooth 77 (96.25)
 Black 2 (2.50)  Textured 3 (3.75)
Ethnicity  Cohesive 48 (60.0)
 Non-Hispanic 72 (90.00) Implant size, cc
 Hispanic 8 (10.00)  Mean ± SD 588.5 ± 144.39
Mean BMI ± SD, kg/m2 25.99 ± 4.15  Range 220–770
Genetic disorder 29 (36.25) Explant size, cc
 BRCA1 20 (25.00)  Mean ± SD 512.3 ± 132.18
 BRCA2 6 (7.50)  Range 180–800
 PALB2 2 (2.50) Difference, cc
 CHEK2 1 (1.25)  Mean ± SD 76.1 ± 78.49
Comorbidities  Range –125 to 295
 Diabetes mellitus 2 (2.50) AlloDerm use 65 (81.25)
 Coronary artery disease 0 (0.00) Mean AlloDerm size ± SD, cm2 364.8 ± 83.24
 Hypertension 10 (12.50) Capsulectomy 80 (100.00)
 Dyslipidemia 16 (20.00) Concurrent fat graft 3 (3.75)
 Bleeding disorder 2 (2.50) Mean volume ± SD, cc 73.33 ± 25.17
ASA class Additional procedures 64 (80.00)
 1 9 (11.25)  Excision of excess tissue 57 (71.25)
 2 66 (82.50)  Contralateral breast procedure 5 (6.25)
 3 4 (5.00)  Salpingo-oophorectomy 4 (5.00)
Smoking Prophylactic discharge antibiotics 48 (60.0)
 Current 3 (3.75) Closed suction drain used 67 (83.75)
 Former 35 (43.75)  Mean drain duration ± SD, days 20.2 ± 6.30
 Never 42 (52.50) Mean follow-up ± SD
 Active marijuana 9 (11.25)  Days 455.4 ± 214.16
Prior radiation therapy 10 (12.50)  Months 15.2 ± 7.14
History of chemotherapy 35 (43.75) IMF, inframammary fold.
Preoperative fat grafting 42 (52.50)
BMI, body mass index; ASA, American Society of Anesthesiologists.
clinical outcomes and morbidity are summarized
operating room was required in two breast revi- in Table 3.
sions (2.5 percent), one (1.25 percent) for delayed The presence of prior radiation therapy (n = 10)
onset hematoma and one (1.25 percent) for infec- or chemotherapy (n = 35) was not associated with
tion. Both of these patients required implant worse clinical outcomes. Acellular dermal matrix
removal and immediate replacement. There were was used for soft-tissue reinforcement in 65 revi-
no failed reconstructions. sions (81.3 percent), and was associated with
In this series, there were six unplanned read- fewer instances of asymmetry (15.4 percent ver-
missions (7.5 percent) following conversion. sus 47.0 percent; p = 0.01), capsular contracture
There were two seromas that did not require any (1.5 percent versus 26.7 percent; p < 0.01), and
further intervention. There was no nipple necrosis subsequent need for cosmetic revision surgery
or nipple loss identified. Incisional wound dehis- (6.2 percent versus 33.3 percent; p = 0.01. The
cence and partial skin necrosis were seen in 2.5 effects of acellular dermal matrix use are summa-
percent and 1.3 percent of conversions, respec- rized in Table 4.
tively. Eleven reconstructions (13.8 percent) were Autologous fat grafting of the mastectomy
treated for postoperative infection. Subsequent skin envelope was performed in 52.5 percent of
cosmetic revision was performed in 11.3 percent conversion patients, before the prepectoral con-
of breast conversions. Capsular contracture devel- version operation. This fat grafting cohort was
oped in 6.3 percent of conversion breasts. Overall associated with fewer instances of asymmetry when

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Volume 145, Number 3 • Correction of Breast Animation Deformity

Table 3.  Overall Postoperative Outcomes and preconversion fat grafting on surgical outcomes
Complications for Patients Undergoing Conversion to are shown in Table 5.
a Prepectoral Pocket Postoperative, prophylactic antibiotics were
Outcome No. (%) prescribed on discharge for 60.0 percent of
patients. Their use was associated with fewer infec-
Total no. of revisions 80 (100)
Unplanned return to OR 2 (2.50) tions (2.1 percent versus 31.3 percent; p < 0.01)
 Hematoma 1 (1.25) following the conversion operation. Infection
 Infection 1 (1.25) data showing the effects of prophylactic antibiotic
Admission 6 (7.5)
 Infection 5 (6.25) use is shown in Table 6.
 Hematoma 1 (1.25)
Hematoma 1 (1.25)
Seroma 2 (2.50) DISCUSSION
Implant exposure 0 (0.00)
Implant loss 2 (2.50) Implant-based breast reconstruction remains
 Infection 1 (1.25) the most common technique for breast recon-
 Hematoma 1 (1.25) struction following mastectomy, with annual rates
Superficial nipple necrosis 0 (0.00)
Partial nipple loss 0 (0.00) rising.9 Although techniques have evolved over
Complete nipple loss 0 (0.00) time to improve cosmesis and patient satisfaction,
Skin necrosis 1 (1.25) use of at least partial muscular coverage with a
Wound breakdown 2 (2.50)
Asymmetry 17 (21.25) dual-plane approach remains the most common
Capsular contracture 5 (6.25) location for implant placement.5 Compared to
Cosmetic revision 9 (11.25) primary subcutaneous implant placement in the
Infection total 11 (13.75)
 IV antibiotics 6 (7.5) past, this technique has been associated with
 Requiring procedure 1 (1.25) lower rates of capsular contracture, and reduced
 Recurrent 1 (1.25) implant visibility and exposure.2
Lymphedema 0 (0.00)
OR, operating room; IV, intravenous.
However, a consequence of either partial or
full implant coverage with the pectoralis muscle
can be the tendency for the implant and skin
compared to patients not undergoing preemp- envelope to animate with pectoralis activation.
tive fat grafting (11.9 percent versus 31.6 percent; One recent study evaluating quality of life after
p = 0.05), less development of capsular contrac- subpectoral breast reconstruction demonstrated
ture (0 percent versus 13.2 percent; p = 0.02), some degree of animation deformity in 100 per-
and reduced need for subsequent cosmetic revi- cent of patients queried, negatively affecting their
sion surgery (4.8 percent versus 18.4 percent; quality of life.10 Other studies assessing outcomes
p = 0.08). These results showing the effects of of subpectoral breast reconstruction have shown

Table 4.  Effects of Acellular Dermal Matrix Use on Reconstructive Outcomes with Conversion to a
Prepectoral Pocket
ADM (%) No ADM p
No. 65 (81.3) 15 (18.7)
Mean age ± SD, yr 50.34 ± 9.53 51.87 ± 9.83 0.580*
Mean BMI ± SD, kg/m2 26.20 ± 4.37 25.08 ± 2.97 0.351*
Mean ASA class ± SD 1.97 ± 0.43 1.87 ± 0.35 0.407*
Mean implant size ± SD, cc 598.38 ± 155.54 545.67 ± 68.00 0.205*
Diabetes 0 (0.00) 2 (13.33) 0.033†
Hypertension 10 (15.38) 0 (0.00) 0.195†
Dyslipidemia 16 (24.62) 0 (0.00) 0.033†
Current smoking 2 (3.08) 1 (6.67) 0.468†
History of radiation therapy 8 (12.31) 2 (13.33) 1.000†
History of chemotherapy 29 (44.62) 6 (40.00) 0.782†
Preoperative fat grafting 37 (56.92) 5 (33.33) 0.151†
Nipple-sparing mastectomy 45 (69.23) 6 (40.00) 0.042†
Prophylactic antibiotics 40 (61.54) 8 (53.33) 0.572†
Asymmetry 10 (15.38) 7 (46.67) 0.014†
Capsular contracture 1 (1.54) 4 (26.67) 0.004†
Cosmetic revision 4 (6.15) 5 (33.33) 0.010†
ADM, acellular dermal matrix; BMI, body mass index; ASA, American Society of Anesthesiologists.
*t test.
†Fisher’s exact test.

637
 Plastic and Reconstructive Surgery • March 2020

Table 5.  Effects of Preconversion Fat Grafting on Postoperative Outcomes

Preconversion Fat Grafting (%) No Fat Grafting (%) p
No. 42 (51.3) 38 (48.7)
Mean age ± SD, yr 49.92 ± 9.82 51.40 ± 9.30 0.494*
Mean BMI ± SD, kg/m2 26.99 ± 4.87 24.89 ± 2.85 0.023*
Mean ASA class ± SD 1.95 ± 0.49 1.95 ± 0.32 1.000*
Mean implant size ± SD, cc 617.74 ± 116.95 556.18 ± 165.27 0.056*
Diabetes 0 (0.00) 2 (5.26) 0.222†
Hypertension 6 (14.29) 4 (10.53) 0.741†
Dyslipidemia 8 (19.05) 8 (21.05) 1.000†
Current smoking 1 (2.38) 2 (5.26) 0.602†
History of radiation therapy 5 (11.90) 5 (13.16) 1.000†
History of chemotherapy 21 (50.00) 14 (36.84) 0.266†
ADM use 37 (88.10) 28 (73.68) 0.151†
Nipple sparing mastectomy 34 (80.95) 17 (44.74) 0.001†
Prophylactic antibiotics 25 (59.52) 23 (60.53) 1.000†
Asymmetry 5 (11.90) 12 (31.58) 0.054†
Capsular contracture 0 (0.00) 5 (13.16) 0.021†
Cosmetic revision 2 (4.76) 7 (18.42) 0.078†
Any infection 6 (14.29) 5 (13.16) 1.000†
IV antibiotics 3 (7.14) 3 (7.89) 1.000†
Procedure for infection 1 (2.38) 0 (0.00) 1.000†
Recurrent infection 0 (0.00) 1 (2.63) 0.475†
BMI, body mass index; ASA, American Society of Anesthesiologists; ADM, acellular dermal matrix; IV, intravenous.
*t test.
†Fisher’s exact test.

Table 6.  Effects of Postoperative Antibiotic Use on Postoperative Outcomes

Antibiotics Used (%) No Antibiotics (%) p
No. 48 (60) 32 (40)
Mean age ± SD, yr 53.00 ± 10.43 47.07 ± 6.75 0.006*
Mean BMI ± SD, kg/m2 25.06 ± 3.59 27.39 ± 4.58 0.013*
Mean ASA class ± SD 2.04 ± 0.36 1.81 ± 0.47 0.015*
Mean implant size ± SD, cc 546.15 ± 145.16 652.03 ± 119.31 0.001*
Diabetes 2 (4.17) 0 (0.00) 0.514†
Hypertension 2 (4.17) 8 (25.00) 0.012†
Dyslipidemia 10 (20.83) 6 (18.75) 1.000†
Current smoking 0 (0.00) 3 (9.38) 0.060†
History of radiation therapy 10 (20.83) 0 (0.00) 0.005†
History of chemotherapy 23 (47.92) 12 (37.50) 0.490†
ADM use 40 (80.33) 25 (78.13) 0.572†
Nipple-sparing mastectomy 28 (58.33) 23 (71.88) 0.244†
Preoperative fat grafting 25 (52.08) 17 (53.13) 1.000†
Any infection 1 (2.08) 10 (31.25) <0.001†
IV antibiotics 1 (2.08) 5 (15.63) 0.035†
Procedure for infection 0 (0.00) 1 (3.13) 0.400†
Recurrent infection 1 (2.08) 1 (3.13) 0.400†
BMI, body mass index; ASA, American Society of Anesthesiologists; ADM, acellular dermal matrix; IV, intravenous.
*t test.
†Fisher’s exact test.

that up to 75 percent of patients are aware of
their animation deformity, 26 percent consider it
severe in nature, and over 50 percent would have
preferred a technique to eliminate it.11
Prior attempts at correction of animation
deformity, including botulinum toxin type A injec-
tion into the pectoralis muscle, and autologous
fat grafting into the plane between the pectoralis
muscle and the overlying breast skin, have pro-
duced only temporary or inadequate correction
of animation. In our opinion, the only definitive
treatment option for this complication is surgical
conversion to a prepectoral pocket. This involves
removal of the existing subpectoral implant,
mobilization and resuspension of the pectoralis
muscle to the chest wall, and placement of a new
prepectoral implant. In doing so, the muscle and
mastectomy skin now become separated by the
prepectoral implant, and contraction of the mus-
cle can no longer result in animation. Two recent
studies have demonstrated efficacy with this tech-
nique in eliminating animation deformity.7,8
Our series of 80 breast conversions to the pre-
pectoral plane demonstrates 100 percent efficacy

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Volume 145, Number 3 • Correction of Breast Animation Deformity

in eliminating animation deformity and at the
same time has proved to be a safe technique with
few complications (Fig. 4). [See Video 1 (online),
which shows the patient from Fig.  4 contracting
her pectoralis major muscles before conversion
with her submuscular reconstruction. See Video 2
(online), which shows the patient from Fig. 4 con-
tracting her pectoralis major muscles following
prepectoral pocket conversion, and elimination of
her animation deformity.] Our overall unplanned
return to the operating room rate was 2.5 per-
cent, which is fairly low considering the number
of prior revision procedures these patients had
in our series, and 12.5 percent of patients (10
breasts) having undergone prior radiation ther-
apy. In fact, neither prior chemotherapy nor prior
radiation therapy demonstrated significant effects
in our outcomes and morbidity in this series, and
we feel that neither factor is a contraindication for
this procedure. In addition, despite a high rate
of using periareolar incisions, we had no nipple-
related complications postoperatively.
The total infection rate in our series was 13.8
percent, which is higher than expected for a clean
procedure. We have seen higher infection rates in
our reconstruction population, which is likely a con-
sequence of reduced vascularity, secondary to rela-
tively thin mastectomy skin flaps. It is our practice
to aggressively treat infections at the earliest sign of
erythema, to preserve the reconstruction and avoid
implant loss. For this reason, our rate of infection
may also be artificially increased, where patients
with mild erythema that could be attributable to
allergic reaction, acellular dermal matrix–related
inflammation, or surgical irritation, are treated
early with antibiotics. For patients who do not show

Fig. 4. A 58-year-old woman with a 15-year history of bilateral submuscular prosthetic breast
reconstruction, shown at rest (above, left) and with the ability to individually animate the right
breast (above, right) and left breast (below, left) with voluntary pectoralis major muscle contrac-
tion. The patient is also shown (below, right) 1 year after conversion to a prepectoral pocket, with
elimination of animation deformity.

639
 Plastic and Reconstructive Surgery • March 2020
rapid improvement on oral antibiotics, early admis-
sion for intravenous antibiotics is also practiced.
We do now routinely send patients home with
prophylactic antibiotics following these operations,
for 7 days. The data in our series has illustrated an
association of reduced infections following conver-
sion operations with prophylactic antibiotics, and
was an impetus to create a standard protocol for 1
week of oral antibiotics at the time of discharge. This
is consistent with prior published literature showing
protective effects of prophylactic postoperative anti-
biotics in prosthetic breast reconstruction.12,13
A preoperative understanding of the patient’s
soft-tissue quality is important to be able to set expec-
tations regarding the need for subsequent cosmetic
revisions. Most patients continue to have thin and
attenuated mastectomy skin envelopes, even years
out from their original mastectomy and subpecto-
ral reconstruction. As such, we have found a distinct
benefit to supporting the soft-tissue envelope with
acellular dermal matrix at the time of conversion.
This serves to support the new prepectoral implant
and ensure that it is not physically supported by
only skin after conversion surgery. If this were the
case, implant descent and the need for future revi-
sion procedures would be significantly increased.
The use of acellular dermal matrix in this
population also carries the benefit of reducing
the rates of capsular contracture, which has been
previously shown.14 This is especially important
following this conversion operation, where place-
ment of the implant in a new prepectoral plane
would likely result in higher risk of capsular con-
tracture moving forward, if no acellular dermal
matrix is used. We typically use a complete ante-
rior wrap with partial coverage of the posterior/
inferior implant in these patients, and avoid a
prepectoral P1 technique as to avoid potential
devascularization of the pectoralis muscle flap.
We found that using an acellular dermal
matrix for implant coverage at the time of surgery
was associated with a decreased risk of capsular
contracture (1.5 percent versus 26.7 percent in
our series). It was also associated with less need
for secondary cosmetic revision procedures, likely
because of providing better contour, more precise
implant and pocket placement, and masking of
rippling or prominence of implant edges. How-
ever, this effect may be confounded because of
some heterogeneity between groups that received
and did not receive acellular dermal matrix, which
is reflected in Table 4. We typically use a smooth,
round, cohesive implant in combination for simi-
lar effect, and to provide more superior pole full-
ness than older implants.
640
Similar positive benefits were seen in patients
who had undergone preemptive fat grafting,
approximately 1 to 2 months before their con-
version operation. More recently in this series,
the senior author began offering preemptive fat
grafting to any patient with thinner or attenu-
ated soft tissue and skin envelopes (Fig. 5). [See
Video 3 (online), which shows the patient from
Fig.  5 contracting her pectoralis major muscles
before conversion with her submuscular recon-
struction. See Video 4 (online), which shows
the patient from Fig. 5 contracting her pectora-
lis major muscles following prepectoral pocket
conversion, with elimination of her animation
deformity.] These patients are brought to the
operating room, and an average of 75 to 150 cc is
injected per breast, in the subdermal plane of the
superior pole skin flaps. This serves to thicken
the skin flap, making it safer to subsequently sep-
arate skin from pectoralis muscle when the con-
version is performed. Furthermore, we believe
this has reduced the risk of clinical rippling and
need for revision procedures following conver-
sion surgery, as a result of the enhanced soft-
tissue quality over the new prepectoral implant.
Finally, a protective benefit of autologous fat has
been illustrated by the clinically reduced rates of
capsular contracture experienced following con-
version operations, when patients have been pre-
viously injected with fat.
Based on the clinical outcomes assessment in
our series, it is now our practice to use acellular
dermal matrix in all conversion operations. In
addition, we incorporate fat grafting as a neces-
sary step before performing prepectoral pocket
conversion, in any patient deemed to have thin
upper pole mastectomy skin flaps, identified
by a pinch test less than 1 cm. Patients will typi-
cally wait a minimum of 6 to 8 weeks following
fat grafting before proceeding with prepectoral
pocket change.
Our clinical experience has taught us that sub-
pectoral-to-prepectoral conversion operations are
accompanied by an extremely high rate of satisfac-
tion in patients, as animation deformity can result
in significant distress and discomfort. Future stud-
ies from our institutional experience will include
a validated BREAST-Q survey assessment of these
patients, to quantify their satisfaction experienced
with correction of animation deformity.
CONCLUSIONS
The conversion of a previous subpectoral
breast reconstruction to the prepectoral plane for
Volume 145, Number 3 • Correction of Breast Animation Deformity

Fig. 5. A 49-year-old woman with a 5-year history of bilateral submuscular prosthetic breast
reconstruction, shown at rest before preemptive fat grafting (above, left) with a thin soft-tissue
envelope. The patient is also shown 2 months later, following fat grafting with improved breast
skin flap thickness at rest (above, right) and with symptomatic (painful) animation (below, left) of
her bilateral submuscular reconstructed breasts. The patient is then shown (below, right) 1 year
after conversion to a prepectoral pocket, and elimination of animation deformity.

correction of animation deformity is a safe and ‍REFERENCES

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that can reduce complications and the need for
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of the mastectomy skin envelope, and routine
administration of prophylactic antibiotics. When
performed in such a manner, we believe aesthetic
outcomes have been excellent, and correction of
animation deformity has been complete.
Hani Sbitany, M.D.
Division of Plastic and Reconstructive Surgery
Mount Sinai Medical Center
425 West 59th Street, 7th Floor
New York, N.Y. 10019
hani.sbitany@mountsinai.org
Twitter: @DrHaniSbitany
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