Secondary mammaplasty with monobloc resection and implant repositioning in the partial retropectoral pocket
Mamoplastia secundária com ressecção em monobloco e neoposicionamento do implante no espaço retropeitoral parcial

INTRODUCTION

Breast augmentation with a silicone implant is one of the most common plastic surgery procedures in Brazil and worldwide^1-3. Considering that some of these patients may need some type of secondary intervention^4-7, ranging from minor scar-repairing procedures to complex surgeries for complete breast reconstruction, it is important for plastic surgeons to be prepared to meet patient expectations and deal with possible difficulties.

Over the last decades, the rate of reoperations for breast augmentation has remained unchanged at about 20% after 3 years regardless of the type of implant⁸.

Therefore, it is important to know different secondary surgical methods in order to provide solutions for complex cases, inadequate results, and patients dissatisfied with primary surgery results.

OBJECTIVE

The objective of this study was to evaluate patients with previous silicone implantations undergoing secondary mammaplasty, presenting an alternative approach with en block resection of breast tissue, fibrous capsule, and silicone implant, followed by implant repositioning in the partial retropectoral pocket.

Methods

This was a cross-sectional retrospective study to analyze medical records and photographic documentation of patients who had undergone a primary breast implant surgery at least 6 months before the secondary breast surgery in the period from January 2013 to March 2017. All patients were operated by the author in his private clinic.

The analysis followed the principles of the Declaration of Helsinki (2000) and resolution 466/2012 of the National Health Council regarding ethical and legal aspects of research involving human beings in Brazil.

This study included 24 cases of breast surgery with en block resection and implant replacement and repositioning in the partial retropectoral pocket during the abovementioned period.

The patients were operated by the same professional, regardless of where the primary intervention was conducted. After an initial consultation with general evaluation and surgical planning, the patients underwent clinical and cardiological evaluation and were considered fit for the procedure.

The patients underwent laboratory screening, chest radiographic examinations, and breast imaging exams. According to age and need for diagnostic clarification, some patients underwent breast ultrasound, mammography, and/or nuclear magnetic resonance imaging. Patients had a consultation preferably one day before surgery for photographic documentation and clarification of any questions.

The surgery indication was based on the presence of at least one of the following criteria: patient’s motivation to improve breast esthetics; and changes on physical examination and/or imaging exams that justified mammaplasty with implant replacement.

Therefore, the objectives of the surgery were defined considering, above all, the patient’s expectations regarding breast size.

Progress and results were evaluated by comparative physical examination and using photographic records 60 days and 6 months after the procedure at regular postoperative consultations and considering the patients’ validation of results. Ultrasound examination was requested for all cases 6 months after the procedure to verify proper placement of the breast implants.

Preoperative marking

After marking the midline throughout the chest, breast markings began at point A, bilaterally. Point A corresponded to the new position of the nipple-areola complex (NAC), and so it was positioned on the mammary midline above the anterior projection of the mammary fold^9-12. Points A were marked strictly equidistant to the thoracic midline (TML) and to the sternal notch to identify and correct NAC asymmetries.

Vertical lines were delimited by skin traction (medially and laterally) in relation to a point on the mammary fold (called point X), positioned at a distance 1 to 2 cm shorter than the distance from point A to the TML. After the vertical markings were defined, the points corresponding to the height of the lower border of the new areola position (called points B and C) and the future point of the junction of the vertical incisions in the mammary fold (called points D and E) were marked.

The distances of points B and C and D and E from point A were between 3.5 and 4 cm and 10 and 11 cm, respectively. This marking was based on overall breast characteristics (skin, breast tissue density, base diameter, and need for projection) and size of the implant to be used.

Next, horizontal resection lines were delimited by lines marked between points D and E and the medial and lateral extremities of the mammary fold line. During these markings, skin traction was very carefully applied so that points D and E were more distant than point X from the medial and lateral borders of the inframammary fold scar, in order to prevent over-resection and excessive tension in vertical sutures, especially with the use of larger implants.

Subsequently, all markings were photographed (Figure 1) and the positions of the future scars were shown to the patient.

Figure 1 - Preoperative marking.

Figure 1 - Preoperative marking.

The patients underwent general anesthesia or epidural block associated with intravenous sedation in a hospital environment, respecting the anesthetic criteria and the joint decision of the anesthetist and the patient. Analgesic, anti-inflammatory, and antibiotic medications were used during and after surgery.

Operative technique

The patient was placed in the supine position with approximately 30° of elevation; skin incisions on the previous marking lines and de-epidermization of the periareolar skin were then performed (Figure 2A) for subsequent superior rotation of the NAC with the superior or superomedial pedicle¹³, according to the previously defined point A position or the need to adapt to breast tissue resections and size of the new implant. En bloc resection included excess skin and breast tissue at the lower breast pole, capsule, and implant (Figures 2B, 2C, and 2D). Microdissection needles (Colorado Type, Black & Black Surgical, Inc.) were used for electrocautery detachment to facilitate hemostasis and the perfect separation of the capsule and surrounding tissues.

Figure 2 - En bloc resection of the skin, breast tissue, fibrous capsule, and implant.

Figure 2 - En bloc resection of the skin, breast tissue, fibrous capsule, and implant.

After complete resection of the mammary tissue, capsule, and implant, no scar tissue or residual capsule was left. The detached area was then exhaustively washed with 0.9% saline solution and protected with a wet compresses for subsequent hemostatic testing when necessary.

The same procedure was performed on the contralateral breast, followed by bilateral total en bloc resection of the structures (Figure 3). The capsule was opened outside the surgical field for analysis of integrity, deformities, type, and size of the patient’s implant (Figure 4). After delimitation and symmetrization of the detached areas in both breasts, bilateral retromuscular pockets were made starting with the incision of the pectoral muscle in the nearest portion of the mammary fold^3,7 (Figure 5).

Figure 3 - Bilateral resection.

Figure 3 - Bilateral resection.

Figure 4 - Separation of implants and breast tissue.

Figure 4 - Separation of implants and breast tissue.

Figure 5 - Incision in the pectoralis major muscle to prepare a retromuscular pocket.

Figure 5 - Incision in the pectoralis major muscle to prepare a retromuscular pocket.

After detachment of the pectoralis major muscle up to the medial insertion limit - as necessary to accommodate the new implant and to avoid superior displacement due to pressure resulting from muscular action - hemostasis was rigorously tested in the anterior and posterior regions of the muscle, bilaterally.

The pectoral muscle was sutured to the breast tissue to facilitate implant accommodation in the retromuscular pocket, avoiding migration of the implant to the anterior part of the muscle and providing muscle flap stability to the breast tissue. Suturing was started with a stitch on the mammary midline corresponding to the point of support at the level of the 4^th or 5^th intercostal space and NAC projection (Figure 6A). After that, two to four stitches were made on each side along the lower border of the pectoralis major muscle using Mononylon^® 3.0 and inverted knot sutures so that the thread was not in direct contact with the silicone implant (Figure 6B).

Figure 6 - Suture of the pectoral muscle and breast tissue.

Figure 6 - Suture of the pectoral muscle and breast tissue.

After the implant (textured, round, high or super high profile, Eurosilicone, Mentor Corporation, or Natrelle brands) was accommodated in a partial retromuscular pocket, mammary suture was started at the junction of the pillars at the X-point projection, respecting anatomical planes and perfect accommodation of mammary, subdermal, and dermal tissue (Figure 7).

Figure 7 - Plane suture restructuring of the breast on the implant.

Figure 7 - Plane suture restructuring of the breast on the implant.

Closed suction drains were used for 1 to 5 days, depending on the volume and appearance of the drained fluid. The drains were placed in the submuscular pocket with some holes in the inferior lateral portion of the breast (Figure 8B). Right after surgery, it was possible to see adequate mammary tissue coaptation with the implant and greater breast support compared to those preoperatively (Figures 8A and 8B).

Figure 8 - Immediate result.

Figure 8 - Immediate result.

All patients received verbal and written instructions on specific postoperative care in order to avoid implant displacement, especially in the first 60 postoperative days.

RESULTS

The mean age of the operated patients was 50 years (minimum 24 and maximum 73 years) and the mean time since the first implant surgery was 10.1 years (minimum 1 year and maximum 25 years).

This study included 24 secondary mammaplasty procedures involving mammary implant replacement and repositioning in the partial retropectoral pocket during the study period. All cases presented breast changes on physical examination, including breast ptosis (moderate to severe), capsular contracture, improper implant positioning, and breast asymmetries.

Dissatisfaction with the results of the primary surgery was reported in 10 (41.6%) cases, and most of these patients had undergone breast augmentation mammaplasty less than 10 years before. The other 14 (58.4%) patients reported being satisfied with primary surgery results; however, the changes that appeared over time motivated them to undergo a new surgery.

Implant-related changes in image examinations (mammography, ultrasound, and/or nuclear magnetic resonance) were described in 7 (29.1%) cases. Capsular contracture (Baker Classification II¹⁴ or above) was identified during physical examination and in imaging exams in 7 (29.1%) cases, and 2 (8.3%) cases showed evidence of intracapsular implant rupture. Six (25%) primary breast augmentation procedures were performed by the author and 18 (75%) by other professionals.

Of the cases in which the patient’s clinical history was not available, the implant volume was accurately reported or some type of implant documentation was maintained in only 4 (22.2%). Thus, implants with volumes different than those reported by patients were found in 14 cases, corresponding to 77.7% of surgeries. Implant volume could not be identified in one case because the patient had no relevant information on volume and it was a ruptured smooth implant. It was the oldest implant (25 years) analyzed. During surgery, textured implants were identified in 16 (66.6%) patients, polyurethane-coated implants in 7 (29.1%), and smooth implants in 1 (4.1%).

The mean volume of the implants replaced during surgery was 233 cc (minimum 135 cc and maximum 300 cc) on the right side and 235 cc (minimum 135 cc and maximum 375 cc) on the left side. The mean volume of the implants repositioned during surgery was 341 cc (minimum 200 cc and maximum 450 cc) on the right side and 341 cc (minimum 220 cc and maximum 450 cc) on the left side. The mean volume of the implants used was the same for both sides, although different sized implants were used to compensate for asymmetries that could not be corrected only by resecting excess skin and breast tissue. Implant volume tends to be larger in secondary surgeries to compensate for glandular atrophy and provide greater breast tissue support, especially when placed in the retromuscular plane.

Table 1 shows information on patients’ complaints, medical evaluation, types of implant coating, and volume of implants replaced and repositioned in this study.

Table 1 - Clinical information and breast implant details of the cases analyzed in the study.

There was no implant displacement, retroglandular migration, or breast asymmetry requiring corrective surgery at the evaluation 60 days after the surgery, using physical examination, photographic records, surgeon’s technical validation, and patients’ approval as parameters. The patients had no complaints of residual excess skin at the time of this evaluation. Mild to moderate mammary ptosis was reported in 3 (12.5%) cases, mainly related to weight loss during the period, previous presence of stretch marks, and sagging body skin. Additional skin resection was scheduled, without any need for direct intervention on breast implants.

The patients underwent breast ultrasound examinations 6 months after the surgery, which showed no implant rupture, contour irregularities, residual seroma, or other changes related to the surgery analyzed in this study.

Surgical complications included 4 cases of unilateral suture dehiscence in the inframammary fold, representing 8.3% of the 48 operated breasts. Partial unilateral areola necrosis occurred in one patient, corresponding to 2.8% of the operated breasts. This specific patient had undergone the primary procedure and two breast repair surgeries. All complications were resolved under local anesthesia. Complete suture dehiscence, hematoma, infection, or other major complications were not reported in the patients undergoing the procedure described in this study.

DISCUSSion

Given the significant number of women undergoing breast augmentation or breast repositioning surgeries with silicone implants in recent years, surgeons should find practical and objective secondary mammaplasty solutions, providing satisfactory results to patients and avoiding excessively long procedures or high blood loss.

In 2001, Melega et al.¹⁵ described the surgical approach for en bloc resection in cases of capsular contracture correction through an incision on the previous scar, dissecting the fibrous capsule with blunt scissors. This procedure was called “capsulectomy without capsulotomy”.

En bloc resection of the skin, mammary gland, fibrous capsule, and implant has multiple benefits during a highly complex surgery such as mammaplasty associated with implant replacement.

Some of the benefits are as follows:

Different techniques to approach the fibrous capsule have been proposed in previous studies^15-20, many of them preserving the whole capsule or part of it, with favorable results. However, the maintenance of fibrous tissue in contact with the implant, probably incorporating silicone gel extravasation residues, can have disastrous consequences, especially the occurrence of potential bacterial contamination and local infection, which would result in implant removal^15,21-24.

A broad review of the literature on capsular contracture management shows that both capsulotomy and capsulectomy can be effective, suggesting total capsulectomy in cases of retroglandular implant contracture²⁵.

In 2006, Spear²⁰ described a technique for capsular contracture correction with total or partial capsulectomy and implant repositioning to the retropectoral plane using marionette half-mattress sutures to obliterate the subglandular space, obtaining satisfactory results with low risk of capsular contracture.

The complexity of the surgery and the instability of the structures mobilized in the presented procedure evidently require preventive measures to avoid implant detachment and migration to the retroglandular space, which would be disastrous, especially if unilateral. Thus, we used resistant and non-absorbable thread for direct suture with multiple stitches to achieve perfect adherence of the lower border of the pectoral muscle to the mammary tissue.

Although implants are not completely covered by the pectoral muscle, covering the superomedial portion of the implant provides a natural result. In addition, a careful detachment of the lower part of the pectoral muscle and the maintenance of medial and lateral insertions allow implant accommodation, providing greater stability and reduced risks of postoperative displacement^3,19,26 (Figures 9A-9D).

Figure 9 - Results report.

Figure 9 - Results report.

In the studied cases, the use of polyurethane-coated implants and their complete adherence to the fibrous capsule resulted in a more practical resection even with varying degrees of capsular contracture. Fibrous capsules of textured implants were thinner, and implant instability due to the presence of residual seroma or pockets bigger than necessary resulted in more difficult resection.

The complication rate corroborated the results of previous studies, even considering the complexity of the procedure and the fact that these are secondary breast surgeries^2,4,5,15,19. No interventions were required for surgical repair of residual breast ptosis, implant displacement, or breast asymmetries during the postoperative follow-up of the studied cases. Moreover, none of the cases presented capsular contracture until this manuscript was prepared. The results of this study show implant stability and low long-term capsular contracture index, even considering the relatively short follow-up period.

Proper planning and implant positioning are essential in breast augmentation surgeries. Therefore, it is important to know different secondary or reparative surgery methods in order to provide solutions for complex cases, inadequate results, and patients dissatisfied with primary surgery results.

CONCLUSION

En bloc resection and implant repositioning in the partial retropectoral pocket with sutures attaching the pectoralis major muscle to breast tissue is an alternative to improve secondary breast surgery, providing favorable results in cases of excessive mobility or capsular contracture in implants initially placed in the retroglandular position.