Ma ,agement of Di:,placed Breast Implants

Editor's note: I extend my heartfelt thanks to the mode "- choose a distance of 21 cm from the sternal notch,
ator, V. Leroy Young, VID (board-certified plastic sur- assuming that the patient is 5 foot 4 inches to 5 foot 8
geon, St. Louis, MO), cmd to panelists L. Franklyn inches tall. If the nipples required elevation, I would use a
Elliott, MD (board-certified plastic surgeon, Atlanta, periareolar mastopexy and discuss the pros and cons of
GA); Claude Lassus, MD (Nice, France); and Walter J. silicone gel-filled implants versus saline-filled implants. In
Peters, MD (board-cert/fied plastic surgeon, Toronto, many patients who require replacement implants, silicone
Ontario, Canada) for sharing their opinions and clinica gel-filled devices are a better choice because they are
experiences for this discussion. associated with less risk of skin wrinkling and implant
palpability. Unfortunately,
Dr. Young: The first patient
-- for physicians who are not
(Figure 1) is a 28-year-old
participating in the U.S. Food
woman who had bilateral
and Drug Administration
subglandular breast augmen-
(FDA) protocols, silicone
tations with 350 ml smooth-
gel-filled implants are not an
surface, silicone gel-filled
option.
implants through a periareo-
lar incision. Her breasts were Dr. Young: If the implants
symmetrical before augmenta- were in a submuscular posi-
tion. She has bilateral grade II V. Leroy Young, MD L. FranklynElliott, M D tion rather than a subglandu-
capsular contractures. She is lar position, would your
unhappy because the right thoughts about the cause be
implant is higher than the left different?
implant. Dr. Elliott, whaE do
Dr. Elliott: Not particularly. 1
you think caused this prob-
lem, and how can it be avoid- think the incidence of capsu-
ed? We would also like to lar contracture is lower with
know how you would correct submuscularly placed devices.
this problem. However, symptomatic and
differential contractures can
Dr. Elliott: This is a relatively Claude Lassus, MD Waiter J. Peters, MD O c c u r with submuscular
common problem that is usu- implants.
ally caused by asymmetric
upward forces associated with capsular contracture. For Dr. Young-" Could failure to detach the muscle inferiorly
example, a grade III capsular contracture on the right produce this type of problem in a submuscularly placed
versus a grade II capsular contracture on the left could implant?
displace the right implant superiorly. However, because Dr. Elliott: Inadequate detachment of the pectoralis mus-
the two breasts are equally soft, capsular contracture is cle is more likely to produce lateral displacement and
not the cause, and I would assume that the difference tightness medially than superior displacement. However,
exists because the right implant was placed higher than inadequate dissection inferiorly leads to superior dis-
the left implant. Patients with this type of deformity are
placement.
frequently unhappy with both breasts and usually have
better results when both breasts are revised. The position Dr. Young: If you reoperated on this patient, would you
of her nipples appears to be slightly low with a supraster- place the implants in the same subglandular position, or
nal notch to nipple distance that is greater than normal would you place them submuscularly? Also, would you
(18 to 24 cm); I would measure this distance. I usually use textured or smooth implants?

AESTHETIC SURGERY JOURNAL - JULY/AUGUST 1997 24'7

 large areola, and I
would not hesitate to
operate again
through the same
scar. However, in
patients with small
areolae and when the
integrity of the
implant is unknown,
an inframammary
incision is safer and
Figure 1. A 28-year-old patient with bilateral grade II capsular contractures. Her right breast implant is higher than allows better expo-
her left implant.
sure.

Dr. Lassus: I would

Dr. Elliott: My first choice would be
subglandular placement because this
patient has had implants for several
years and her skin is stretched. I
have a harder time placing implants
under the muscle in secondary pro-
cedures because achieving full
expansion of the skin requires
extreme release of the-muscle, after
which the implant is not truly sub-
muscular. I would use textured
implants because they are more like-
ly to result in soft breasts.
Dr. Peters: The lateral
view demonstrates a
tremendous amount of
upper fullness, which
leads me to suspect that
she may have a more
severe contracture on that
side rather than initial
malplacement. If she had
a more severe contracture
on the right side, would
you do a capsulectomy, a
partial capsulectomy, or
an inferior capsulotomy?
Dr. Elliott: I do total capsulectomies
only when calcification is present. I
perform selective or partial capsulec-
tomies to gain adequate release in
the proper direction. The distance
from this patient's nipple-areola to
the inframammary line also needs to
be lengthened to achieve symmetry
with the opposite side and to relieve
the upper pole fullness. I would start
with a partial capsulectomy inferior-
ly and would remove the entire cap-
sule only if that was necessary to
obtain adequate release.
Dr. Peters: Can a secondary proce-
dure such as this be performed safely
through the original periareolar inci-
sion, or would an inffamammary
incision be required?
Dr. Elliott: I do almost all of my pri-
mary augmentations through a peri-
areolar incision. This patient has a
operate on both sides
through the original incisions,
extend the pocket inferiorly by
excising the inferior portion of the
capsule, and replace the implant
with a polyurethane textured im-
plant because the risk of capsular
contracture is less with polyure-
thane devices.
Dr. Peters: In Canada surgeons can
use only saline implants, so gel
devices would not be an option.
Dr, Young: Dr. Lassus, if
you used saline-filled
implants, would you
place them submuscular-
ly or subglandularly?
Dr, Lassus: I would
place the implants sub-
muscularly with release
of the muscle inferiorly.
Dr. Peters: About 85%
of my primary augmenta-
tions are done submuscu-
larly. If I were operating
on both breasts, I would not hesi-
tate to place the implants submuscu-
larly on both sides. However, if I
were operating on the right side
only, I would place the prosthesis
subglandularly because having
implants in different planes can cre-

248 AESTHETIC SURGERY JOURNAL ~ JULY/AUGUST 1997 Volumel7, Number4

ate asymmetry, and I believe
this possibility outweighs the
risks of wrinkling and palpa-
bility.
Dr. Young: The second patient
(Figure 2) has implants that are
too medial (or synmastia). She
is 38 years old and is shown
here 8 years after postsubglan-
dular augmentations with
smooth-surface silicone gel- Figure 2. A 38-year-old patient with synrnastia.
filled implants. Her nipples are
23 cm from the suprasternal
notch. The right and left nipples are
11 cm and 9 cm, respectively, from
the midpoint of the inframammary
crease. Both implants are soft with
grade II capsules. The patient's pri-
mary concern is medial migration of
the implants. Her breasts were sym-
metrical before the operation and
early after the operation. However,
about 3 years postoperatively, the
implants began to migrate inferiorly
and medially. She used breast mas-
sage regularly and had one bilateral
closed capsulotomy 2 years after
augmentation. Physical examination
and mammography reveal
that the implants are intact.
Dr. Lassus, what do you
think caused this problem,
and how would you correct
it?
Dr. Lassus: This patient has
asymmetry of volume that is
reflected in this asymmetry
of shape. The vertical axis of
her left breast is longer than
that of her right breast, and
the transverse axis of the right breast
is greater than that of the left breast.
This problem could have resulted
from asymmetric positioning of the
implants at surgery. However, her
history reveals that this developed
secondarily, which suggests that
Management of DispIaced BreastImplants
something happened postoperative-
ly.
Dr. Young: It followed the capsulo-
tomy.
Dr. Lassus: My strategy would be to
remove both implants through infra-
mammary incisions for better access,
after which I would expect to find
that the implant pockets connect in
the midline.
Dr. Young: That is exactly what was
found intraoperatively.
Dr. Lassus: With these findings I
would extend the right pocket supe-
riorly to raise the breast mound. I
would also excise a strip of the infe-
rior portion of the right capsule and
reapproximate the capsule edges
with 3-0 mersilene running sutures
AESTHETIC SURGERY
to raise the inframammary
crease. To correct the synmastia
I would divide the capsule ante-
riorly and posteriorly just later-
al to the mid-sternal line,
reflecting the capsule latera!ly
on each side. I would suture the
capsular flaps in a "vest-over-
pants" technique to separate
the two pockets and place
polyurethane textured implants
in a subglandular position.
Dr. Elliott: I think the closed
capsulotomy caused this problem,
and the patient now has relative tis-
sue expansion of the right medial
breast, which explains the increased
distance of the nipple from the mid-
line. Correcting the detachment of
the skin from the midline will also
improve the relative appearance of
the nipples. I also would use "capsu-
lar flaps" as described by Dr. Lassus
and repair them with permanent
sutures. 3-0 mersilene is a good
choice because it's soft and won't
perforate an implant like proline or
nylon. I caution against the use of
absorbable sutures such as
vicryl for this problem
because I have seen recurrent
deformities after 3 to 4
months that I believed were
caused by weakening sutures.
Dr. Young: Dr. Peters, if you
performed this procedure in
Canada and the implants
were intact, would you be
allowed to put the original
prostheses back in?
Dr. Peters: No, we're not allowed to
put the original implants back in; we
would have to switch to saline-filled
devices. I agree that nonabsorbable
sutures are important during capsu-
lorrhaphy; we use nonabsorbable
polyester, which would work fine in
JOURNAL ~ JULY/AUGUST 1997 249
this case. For this patient I
would also consider converting
to a submuscular position by
releasing the medial muscle
attachment from ribs 5, 6, and
7. Sometimes it is hard to
obtain a perfect result with syn-
mastia by capsulorrhaphy alone
because suturing the presternal
area in exactly the right posi-
tion is difficult. I am also more
comfortable tacking the medial
area with submuscular implants
because I can take multiple deep
"bites" and reduce the likeli-
hood of dimpling in the overlying
skin.
Dr. Young: Dr. Elliott, can the medi-
al area be secured by postoperative
taping or dressing?
Dr. Elliott: Dr. Peters makes a good
point about obtaining accurate
delineation, because that is exactly
what this patient wants. I would add
a couple of mersilene sutures in the
medial position to tack the deep der-
mis down to the presternal fascia. If
that isn't done, the skin can
ride up. Although you have
repaired and redefined the
capsule, it never really sticks
down well. Because of this, I
prefer to suture the dermis in
place rather than rely on
external tape or dressing.
Using vicryl sutures to fix the
dermis minimizes the risk of
long-term dimpling and
ensures adherence.
I am reluctant to convert to
the submuscular position in
cases like this because I
believe the skin envelope is distorted,
and after adequate release of the
muscle you really have almost no
muscle cover because of retraction of
the muscle. However, if I have to use
250 AESTHETIC SURGERY JOURNAL
Figure 3. A 55-year-old patient with implants that are
too lateral, and visible skin wrinkling.
a saline implant or if a saline device
is requested by the patient, I prefer
to have maximum padding over the
implant. The submuscular position
provides this padding, even though I
know I'm releasing it extensively and
may not have as much muscular cov-
erage as is typical in a primary aug-
mentation.
Dr. Young: One might consider
using a postoperatively adjustable
implant to allow the midline tissues
to adhere before enlarging the
breast. Although I have not done
this, it does have appeal. I have also
seen cases in which surgeons have
tried to correct this deformity by
placing sutures through the skin and
~ JULY/AUGUST 1997
tying them over bolsters. Is that
a good idea, or does it create
too much of a risk for bad scars
in this area?
Dr. Lassus: I think it is a good
idea if you protect the suture
with gauze to prevent the
stitches from injuring the skin.
Dr. Young: The third patient
(Figure 3) has implants that are
too lateral. She is 55 years old
and has 400 ml nominal vol-
ume, textured saline-filled
implants filled to 450 ml in a sub-
glandular position. She has a grade
IV capsular contracture on the right
and a grade II contracture on the
left. Skin wrinkling is visible on
both sides, and both implants are
palpable; the right is worse than the
left. The present implants were used
to replace ruptured silicone gel-filled
implants that had been in place for
12 years. The right and left nipples
are 24 and 22 cm, respectively, from
the suprasternal notch. The right
and left nipples are 11 and
10 cm, respectively, from the
inframammary crease. The
patient is concerned because
the breasts are too lateral
and because of the wrin-
kling, palpability, and severe
capsular contracture of the
right implant.
Dr. Peters: Although this is
.... not an ideal patient for a
submuscular implantation
because of her age and the
looseness of her skin, I
would consider it because I
think it is the only way to
avoid the wrinkling and other defor-
mities that we see.
Dr. Young: Do you think that she
also needs a mastopexy, and if so,
Volumel7, Number4
would you do it at the same time as
the implant replacement?
Dr. Peters: I don't think she needs a
mastopexy. However, if she did I
would not do it at the same time but
rather would remove the implants
and perform a partial capsulectomy
so that the area wouldn't scar down
afterward. I would also caution this
patient that postoperatively her cen-
tral breast skin would be looser than
normal but should improve with
time and that she might need a sec-
ondary mastopexy, but I would try
to avoid it if possible.
Dr. Young: Would you use a con-
toured implant, and would you con-
sider the use of a postoperatively
adjustable implant?
Dr. Peters: In Canada we can't use
any of those types of implants. I
would have to use a textured or
smooth-surface saline implant.
Dr. Bliott: This is an instance in
which it is best to place the implant
beneath the muscle and the subglan-
dular capsule to increase padding.
This is particularly important
because the skin wrinkling seems
to be the most severe deformity.
Having used both smooth and tex-
tured saline implants, I do not think
that the use of smooth saline devices
and overexpansion eliminates wrin-
Management of Displaced BreastImplants
kling and palpability.
However, smooth silicone
gel devices do seem to
work, and if she were will-
ing to have a gel implant
in view of her previous
problems, I would offer
her that option. My pref-
erence for her would be a
smooth silicone gel-filled
implant in the submuscu-
lar position with a circum-
areolar mastopexy
performed at the same
time. My general limit for a
circumareolar mastopexy is
24 cm, so I think that this
approach would correct
her problem and create a
scar only around the
nipple.
I would also like to reduce
the volume of her breasts
slightly, to at least 400
ml--if not to 375 ml. I
would tell this patient that
her breasts would feel
almost as large as they did
previously because they
will have been lifted and
tightened. Skin tightening C
would facilitate submuscu-
Figure 4 . A 36-year-old patient with recurring inferior
lar placement and allow migration of implants.
medial release of the pock-
et, thereby minimizing the
risk of lateral migration.
allows you to release the pectoralis
Dr. Young: Dr. Peters, are these
major muscle from the medial ribs
breasts truly too far from the mid-
and reposition the implants more
line, or is that an illusion? If they
accurately.
are too far apart, is this the result
of improper creation of the pocket, Dr. Young: Dr. Lassus, what
or does the patient have advanced approach would you take to address
ptosis? this patient's problem?
Dr. Peters: I think it's a bit of both. Dr. Lassus: I would make a submus-
Submuscular positioning would cular pocket with extension medial-
improve this problem because it ly, followed by reinsertion of smaller
AESTHETIC SURGERY JOURNAL ~ JULY/AUGUST 1997 251
implants and a periareolar
mastopexy performed at the same
time.
Dr. Young: The fourth patient
(Figure 4) is atypical in that she is
one of those rare persons who does
not seem to be able to form a cap-
sule strong enough to constrain and
maintain the position of implants.
She is 36 years old and had bilateral
augmentation 12 years ago with sub-
glandular smooth, silicone gel-filled
implants through a periareolar inci-
sion. The implants migrated inferior-
ly 2 years later, and the
revision included a capsulec-
tomy and replacement of the
devices with polyurethane
textured implants. Her
breasts were improved for
about 4 years, after which
inferior migration recurred.
A second revision was per-
formed with removal of the
polyurethane implants and
replacement with 380 ml
textured silicone gel-filled
implants. The deformity was
improved for a few months but
gradually recurred.
Both of her nipples are 23 cm from
the suprasternal notch. The right
and left nipples are 15 and 12 cm,
respectively, from the inframammary
crease. Both breasts are soft with
grade I capsular contractures. The
patient is very distressed by this
deformity, which is visible in some
types of clothing. When she stands,
her breasts are too low and fall
toward the lateral chest. When she
moves in certain ways, they dislocate
into her axilla (Figure 4, C). This is
embarrassing, and she is uncomfort-
able in the presence of her husband.
Dr. Elliott: I'm not sure I've seen a
252 AESTHETIC SURGERY JOURNAL
case like this. However, I have seen
recurrence of inferiorly displaced
implants after capsulorrhaphy. This
problem can be eliminated in most
patients if permanent sutures are
used for the capsutorrhaphy and
good capsular flaps are developed. I
don't think mere plication of the
capsule is adequate. It is essential to
excise the intervening portion and
suture the raw edges to each other
with permanent sutures. I assume
that patients who have connective
tissue disorders such as Ehlers-
Danlos syndrome are prone to devel-
oping this type of problem. I would
also suggest reducing the size of her
implants to reduce the stress inferi-
orly.
Dr. Young: Do you think a patient
like this would be a candidate for a
Ryan procedure, in which you
advance dermis up to a rib and try
to gain more support?
Dr. Elliott: I wouldn't object to
suturing the subcutaneous dermis to
back up the capsular resection and
repair, especially if the skin appeared
redundant or loose in that area.
Although this patient had a periareo-
lar incision, I would have no objec-
tions to using an inframammary
approach here because that would
~ JULY/AUGUST 1997
allow me to tack the dermis down
to the periosteum or to the inter-
costal musculature, which would
provide secondary reinforcement
inferiorly.
Dr. L a s s u s : Fortunately, I have
never seen a case like this. However,
if I had to treat such a patient, I
would be concerned about the huge
excess of tissue in the lower portion
of the breast, and I am not sure that
working on the capsule only would
solve this problem. Thus I would
perform a vertical mastopexy to
remove a large amount of
that excess tissue at the
lower pole and to maintain
the prosthesis in a higher
position.
Dr. Peters: I have seen a few
patients with this type of
deformity after primary aug-
mentations, but I have seen it
more commonly in sec-
ondary open capsulotomy
cases in which the inferior
area had been released
aggressively. I have also seen this
problem in patients taking pred-
nisone. I think this type of deformi-
ty usually responds well to the
approach described by Dr. Elliott.
Again, it is important to use nonab-
sorbable perman_ent sutures to cre-
ate a new secure inframammary
crease. I have seen one patient in
whom this problem recurred on
about three occasions with three dif-
ferent surgeons. I removed her
implants, sutured a ledge there, and
then put the prostheses back in sec-
ondarily.
Dr. Young: Would everyone agree
that a capsulorrhaphy is the way to
deal with the lateral displacement of
the implants?
Volume17, Number4
Dr. Elliott: Capsulorrhaphy is the
treatment of choice for lateral
implant displacement. If the sutures
are in the capsule only, there is a
separation between the capsule and
the dermis, and dimpling is rare. It is
when you catch the dermis that you
get dermal dimpling. Inferiorly a
"belt and suspenders" approach,
including tacking of the dermis
directly through the inframammary
incision, will give you more assur-
ance that what you've done will
hold.
One thing that we haven't talked
about is steroid instillation in
implants and into the capsule sur-
rounding implants. I think that this
accounts for some of the inferior
migrations that we see. If steroids
are placed around the implant in the
capsule, they obviously settle in the
inferior pocket, which can lead to
this type of deformity.
Dr. Young: I did not obtain a history
of steroid use in this patient's case.
Dr. Elliott: We also have not talked
much about whether these implants
are intact. This is a subject all of us
get a lot of questions about. I per-
sonally try to steer away from this
issue and don't encourage the pur-
suit of the diagnosis of it. I tell
patients that they can have a com-
puted tomography or magnetic reso-
nance imaging (MRI) test, but these
Management of Displaced BreastImplants
can yield faulty results. In this case, I
would plan to replace the implants
regardless of whether they are rup-
tured. Do any of you have some
other thoughts about this?
Dr. Peters: In Toronto, Canada, we
don't pursue the diagnosis of im-
plant rupture because of the limita-
tions of ultrasound and mammo-
gram tests. Magnetic resonance
imaging is not generally available to
most surgeons here. Thus we base
our treatments on clinical findings.
Dr. Young: Dr. Lassus, are the
patients in France worried about
rupture of silicone gel-filled
implants ?
Dr. Lassus: Not really. I am examin-
ing patients whom I operated on 15
to 20 years ago, and most of them
refuse to have their prostheses
changed. They say, "They look
okay, so there is no problem. I don't
want my implants changed." Some
patients are worried about rupturing
because of the media's emphasis on
it, but most of them refuse to have
their implants changed.
Dr. Young: Would everyone agree
that the current scientific evidence
supports the statement that the vast
majority of ruptures or leaks are
intracapsular and that the conse-
quences of an intracapsular leak or
rupture are local and not systemic?
AESTHET[C SURGERY
Dr, Lassus: Yes.
Dr. Young: Does that substantiate
what everyone has said in terms of
not needing to pursue the diagnosis
of a leak or rupture in a patient
without symptoms?
Dr. Elliott: Yes.
Dr, Peters: Exactly. In the explanta-
tion study conducted by my facility,
which has been analyzed quite thor-
oughly, more than 97% of the rup-
tures were intracapsular, and we
were seeing a very select group of
patients to start with.
Dr. Young: This always begs the
question of whether we are looking
at the numerator only--that is, peo-
ple who question physicians about
their implants because of symptoms
or other reasons--making it impos-
sible to establish what the rupture
rate really is in the general implant
population.
Dr, P e t e r s : We are looking at the
numerator only for sure; the denom-
inator remains unknown.
Although polyurethane breast
implants are no longer used in the
U.S., they are selectively available in
certain European countries. 9
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JOURNAL ~ JULY/AUGUST 1997 253