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