Introduction

A patient may opt for implant removal for many reasons, including implant rupture, recurrent capsular contracture, persistent pain, concerns over implant safety or cancer surveillance, or simply because she no longer desires augmentation. While implant removal in and of itself is a straightforward procedure, the management of the degree of breast ptosis following implant removal can present several challenges. Many factors contribute to breast ptosis after implant removal, including involutional changes and parenchymal maldistribution that may have occurred after augmentation, changes in body weight, and gravitational factors, with increasing stretching of the skin envelope. These changes are also related to the time interval between the original augmentation and the implant removal, as well as the size of the implant. A woman’s options regarding explantation include open capsulotomy or capsulectomy and implant exchange, implant exchange with mastopexy, explantation and capsulectomy alone, or explantation with mastopexy. This review will focus on explantation with mastopexy, and will discuss preoperative assessment, operative technique, and postoperative care.

Preoperative Assessment (Table 34.1)

When examining the breast, it is essential to understand the ideal relationships of the various anatomic structures of the breast. In the ideal breast, the nipple position is usually located approximately 2 cm above the projection of the inframammary fold. Ideally, the majority of the breast tissue should be centered behind the nipple–areola complex, without a significant amount of skin from the nipple to the inframammary fold (ideal distance usually approximately 7 cm). Important landmarks include the chest midline, the sternal notch, the inframammary fold, and the breast meridian. The breast meridian is defined as a line projecting from the midclavicular position (usually 6 cm from the sternal notch) to the midportion of the central breast mound, projected onto the inframammary fold. Important measurements include the sternal notch to nipple distance, the nipple to inframammary fold, the nipple to midline, as well as the diameter of the nipple–areola complex. It is also important to assess the density of the breast parenchyma, and the location of the parenchyma with relationship to the nipple–areola complex. Care must also be taken to assess both breasts individually, and note asymmetries with respect to the key breast relationships discussed above.

Table 34.1 Preoperative assessment

There are several important aspects of the preoperative assessment that will guide one’s operative plan. As shown in Table 34.2, it is important to consider the degree of ptosis present – patients with grade 2 or 3 ptosis should be considered for mastopexy after explantation (Table 34.3). One must also consider the patient’s skin tone, as a patient with loose, inelastic skin and multiple striae is likely to require mastopexy in order to preserve favorable breast aesthetics. An accurate assessment of the native breast parenchymal volume and distribution will also weigh in one’s decision regarding mastopexy after explantation. For example, a woman with a small amount of breast tissue will likely have an accentuation of breast ptosis and a loss of superior pole fullness after explantation, and will often require mastopexy to preserve a favorable shape. It is also important to evaluate for potential breast asymmetries, as such differences may actually be masked by augmentation. Asymmetry after explantation may also be present in the patient who had previous problems with implant infection, capsular contracture, or perhaps required multiple previous implant revisions. Lastly, one must evaluate the patient’s own sense of her breast aesthetics, particularly with regard to the patient’s acceptance of visible mastopexy scars on the breast.

Table 34.2 Degrees of breast ptosis

Adapted from Regnault P. Ptosis, asymmetry, tubular breast, and congenital anomalies. In: Owsley JQ, Peterson RA, editors. Symposium on aesthetic surgery of the breast. St. Louis: CV Mosby; 1978.

Table 34.3 Factors predictive of need for mastopexy after explantation

Contraindications for Mastopexy after Explantation

Risk factors that may threaten the vascularity of the nipple–areola complex include a history of smoking, cardiac or respiratory disease, or the need to reposition the nipple–areola complex greater than 4 cm from its current position. Careful assessment of breast tissue thickness surrounding the implant is also essential. Thinner overlying tissue will allow for less undermining and subsequent redraping of breast skin. In these situations, implant removal with delayed mastopexy is probably the more prudent approach. Other contraindications to explantation/mastopexy include the patient’s unwillingness to accept a mastopexy scar. For the patient whose expectations are unrealistic or is perhaps unwilling to accept the scar, implant exchange may offer the best option to preserve both breast aesthetics and the patient’s satisfaction.

Operative Technique

Patient markings

The patient should be marked in a standing position, noting the sternal notch, breast meridian, inframammary fold (IMF), and the new position of the nipple–areola complex. For the patient with mild ptosis and favorable breast characteristics, a short scar vertical mastopexy will often be appropriate. As the amount of skin to be resected will often change after implant removal, we favor a tailor tacking approach in the sitting position after the implant has been removed. For patients with moderate to severe ptosis, a Wise pattern mastopexy affords the versatility to move the nipple–areola complex greater distances and effectively manages large skin excess. The IMF is marked first with the lateral extension following the lateral breast curve rather than following the IMF to prevent a dog ear from occurring laterally. A circumferential wire areola marker (McKissock keyhole marker) is used to mark the new position of the nipple–areola complex. The device is centered 2 cm above the projection of the inframammary fold on the patient shown in Figure 34.1A–F (Fig. 34.1G, H). Curvilinear lines are then drawn from the bottom of the areola marking to the breast meridian at the IMF with the breast on tension superiorly (Fig. 34.1I). The degree of outward curvature is estimated based on the degree of breast laxity and can be confirmed on the operating room table after implant removal. The areola to new IMF distance is then marked and is typically 5–7 cm (Fig. 34.1J). Using the line from this marking to the IMF as the base of an isosceles triangle (a triangle with two equal sides and two equal angles), the remaining medial and lateral triangles are marked (Fig. 34.1K–M). The triangles marked may result in a shorter horizontal scar if wider vertical limbs are able to be drawn based on the laxity of the breast tissue.

Fig. 34.1 A, B, C Patient with silicone gel implants placed 25 years prior in the subglandular space. D, E, F Postoperative photos after complete capsulectomy with implant removal and mastopexy. G Preoperative markings. H–N Markings.O Removal of implant intact with total capsulectomy. P De-epithelialization for mastopexy. Q Inverted T-incision closure.

Intraoperative technique

After completion of markings, the patient is brought to the operating room and placed supine on the operating room table. Preoperative antibiotics are given. General anesthesia is usually administered, although in cases of minor ptosis, local anesthesia with intravenous sedation will often suffice. Skin incisions are then made, depending upon the mastopexy pattern selected. The nipple–areola complex is stretched and incised to a diameter between 38 and 42 cm. De-epithelialization is then performed (Fig. 34.1N). For implant removal, an extracapsular dissection with capsulectomy is performed usually through the lower pole of the breast. The parenchymal incision is usually limited to 4–6 cm. If the implant is ruptured, a small opening is made in the capsule and the implant material removed prior to removing the remaining capsule. We favor complete capsulectomy, although in cases with a thick or densely adherent subpectoral capsule, dissection is occasionally limited to the anterior aspect of the capsule (Fig 34.1O).

Regardless of the mastopexy pattern selected, it is important to sit the patient up after capsulectomy and implant removal. The degree of skin removal is often much greater than the preoperative markings indicated, and it is often best to utilize a tailor-tacking approach in order to best shape the central breast mound. We favor conservative parenchymal undermining in order to recreate the central breast mound, and maintain our flaps at least 1 cm thick (Fig. 34.1P). Final closure is performed with absorbable inverted dermal sutures, followed by subcuticular closure and dermabond (Ethicon) or Steri-strips. Drains are usually placed. A second patient example is shown in Figure 34.2A–F.

Fig. 34.2 A, B, C Patient with silicone gel implants placed 20 years prior in the subglandular space and previous mastopexy. D, E, F Patient underwent bilateral capsulectomy and implant removal with re-do mastopexy.

Dressings and Postoperative Care

Gauze dressings are applied to the breasts, followed by a surgical bra. Explantation with mastopexy is usually performed in an outpatient setting, unless it is done in conjunction with other inpatient procedures. The patient is instructed to change the dressings on the second postoperative day and clean the suture lines with hydrogen peroxide. If a drain has been placed, the drains are usually removed in the office within 1 week. The patient is then allowed to get the incision lines wet. Skin flaps are inspected for signs of ischemia on the first postoperative visit. Sensory changes in the skin and nipples are noted as well. Follow-up visits are usually scheduled at 1 month, 6 months, and 1 year to assess the aesthetic outcome, scars, and any sensory changes in the skin.

Conclusion

It is always important to assess the patient’s needs as carefully as possible, so that both patient and physician are satisfied with the outcome of surgery (Fig. 34.2 shows a representative example). Implant removal will often exacerbate the degree of ptosis present, and both the patient’s skin quality, and amount and distribution of native breast tissue will determine postexplantation breast aesthetics. Proper recognition of the need for mastopexy following explantation helps to reduce the necessity of an anesthetic at a delayed date. For high risk patients such as smokers or those requiring the nipple–areola complex to be moved greater than 4 cm, we advocate mastopexy 2 to 3 months following explantation.