Strattice for Revision Aesthetic Breast Surgery in Elite Athletes

Capsular contracture occurs when the lining around a breast implant contracts aggressively. When capsules are not removed in their entirety on the anterior surface of the breast, then the breast can not expand or splay out over the new implant in its entirety.

Occasionally, in the re-operative or revision breast surgery patient implants can become infected and need to be removed for several months while the infection completely resolves.

In these patients, I find that optimal results are achieved when the capsule remnants are removed completely prior to the placement of new implants. Strattice can then be used to line the breast implant pocket. When Strattice is used to line the breast implant pocket, the inframammary fold can be set, malposition can be adjusted, and in the thin patient rippling can be improved by the addition of another layer.

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Strattice for Revision Aesthetic Breast Augmentation

We are starting to see many patients come from out of state to have their revision augmentation procedures or capsulectomy surgeries performed at the Roxbury Clinic & Surgery Center. I have been using the Strattice in the manner as taught to me by Neal Handel, M.D. When working through small incisions, I have found the use of appropriately and carefully placed marionette sutures to align the Strattice in correct position while the remaining sutures are performed through the limited incision.

I have found Strattice to be very helpful in the revision breast augmentation patient who has rippling, implant palpability, synmastia, bottoming out, and fold asymmetry. I have also found Strattice to be helpful as a barrier between the nipple areola complex incision and the capsule of the breast implant.

I remember repeatedly, the lessons on tendon healing by one of my great mentors, Malcolm Lesavoy, M.D. He would always describe the "one wound/one scar" theory for tendon healing. I find that the same theory can apply to breast implant capsules.

Frequently, I see patients who present for capsular contracture surgery who have a thickened scar beneath their periareolar incision with a "scar rind" that is aggressively fixed to their underlying capsule. It is my belief that the interposed Strattice may prevent the "scar rind" that I frequently see beneath the periareolar incision that is firmly fixed to the capsule. I hope this has great implications for reducing capsular contracture.

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No Touch Teqhnique Breast Implant Delivery

I have been using the Keller Funnel routinely for my periareolar and transaxillary breast augmentation cases. The Keller Funnel allows me to deliver larger implants through a smaller incision without traumatizing the breast implant, the skin, or having the breast implant come into contact with the skin.

I believe strongly that this "no touch technique delivery system" can help reduce the incidence of capsular contracture. It is of paramount importance to me that my patients receive great results and that I try to do everything possible to minimize complications.

Brian P. Dickinson, M.D.

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Revision Augmentation Mastopexy Surgery

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I have found an increasing number of women who present to my office in consultation who had saline breast implants placed ten years ago and who are now requesting removal and replacement of their mammary implants for highly cohesive silicone gel mammary prosthesis.

Often these women underwent reduction mammoplasty with an implant to maintain upper pole fullness, but now want to change to an implant with a slightly higher profile to deliver more breast projection.

We are seeing more women present from out of state who come to Newport Beach and Beverly Hills who have capsular contracture and who now want to have their breast implant capsules removed, saline implants replaced for silicone gel implants, and a simultaneous breast lift.

These operations are challenging to preserve the blood supply to the nipple areola complex as previous operations contribute to scarring and necessitate experience with these cases to deliver consistent results.

Bilateral capsulectomies, implant exchange, and mastopexy are commonly performed operations in Newport Beach and Beverly Hills.

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Breast Implants. Saline Implant Valve Failure with Capsular Contracture

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I am seeing more and more women in consultation in my office with deflation of their saline breast implants. In fact, twice this month we had women who presented with the development of pain around their breast implant with an associated distortion of the breast shape secondary to breast implant valve failure.

It has been my experience that the development of a capsular contracture around the breast implant changes not only the shape of the breast implant capsule complex, but may incorporate around the valve of the saline implant (as shown in the image above).

Either continued contraction of the breast capsule resulting in a change in the surface area to volume ratio and/or ingrowth of the capsule to the valve disrupts the valve and allows the saline to extravasate. These women often present with continued pain and the apparent deflation of the implant can be distressing to the patient.

In these cases I recommend that women undergo removal and replacement of their breast implants and capsulectomy. Many women are opting now to exchange their saline implants for silicone gel breast implants.After these surgeries, patients are very happy with the new contour of their implants and their pain is often markedly improved.

Brian P. Dickinson, M.D.
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The Keller Funnel for Silicone Gel Implant Delivery

Today was truly a great day of cases. As the breast augmentation, revision breast augmentation, and capsular contracture surgery practice grows, I continually look for ways to improve patient outcomes, reduce patient recovery time, reduce incision length, and prevent capsular contracture

I have found that the Keller Funnel facilitates delivery of silicone gel implants through smaller incisions and allows me to employ a no-touch delivery technique whereby the gel implant does not come into contact with the nipple areola complex or the axillary skin when placing implants. I found that the Keller Funnel greatly facilitated today's cases and I will use it for the breast augmentation cases later in the week.

I anticipate that the no-touch delivery technique is one method to further reduce the prevalence and incidence of capsular contracture. I look forward to continued success with is device.

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Capsular Contracture: Reconstructive Breast Surgery or Revision Aesthetic Breast Surgery?

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As I continue to learn about both aesthetic and reconstructive breast surgery, I find that the same tools, skill sets, and planning that I use for aesthetic breast apply to reconstructive breast surgery and vice versa.

Frequently, I see many women in consultation who have undergone first a breast augmentation, second a breast reduction, and often present desiring further reduction of their breasts or require surgery for capsular contracture.

I enjoy these challenging cases as it is important to be knowledgeable of the blood supply of the nipple areola complex, the prior surgeries, and how to most effectively manage the capsular contracture.

Women who present after numerous operations often have thinning skin or breast tissue, asymmetry, capsular contracture, or unwanted motion of the implant, and desire correction.

I have found that the breast surgery techniques taught to me by Neal Handel, M.D. have been very effective for identifying, addressing, and managing these difficult cases. Capsular contracture can be very painful for the patient and interfere with daily activities and be psychologically distressing.

The patient in the above photograph is happy with her removal of her saline implants in exchange for silicone implants, change of implant plane, nipple areola reduction, and mastopexy. The scars are still hyperemic in this early one month post-operative result. I routinely educate patients that scars tend to be the most indurated and red approximately one month after surgery and then soften as the collagen in the scar remodels.

I have found that as larger saline implants are removed and exchanged for smaller lighter silicone implants, it is easier for patients to excercise, return to the gym, and loose weight.

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Mastopexy Augmentation Reductions.

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Frequently, I encounter more women in consultation who present to my office desiring a revision of their breast augmentation from 8 to 10 years prior. Frequently these women have had saline breast implants in for almost ten years and now want to exchange their saline breast implants for silicone breast implants.

Often women who have had larger implants and now want to downsize desire to have the breasts placed more centrally on their chest wall away from their armpits, with a reduction in the size of their areola, and a lift of the breast.

Depending upon the age of the patient and whether or not she has had children and/or breast fed, the incision pattern used to make the breast appear more youthful depends upon the degree of breast ptosis. Breast ptosis or the "breast fall" can be corrected by different methods or incisions patterns depending upon the degree of breast ptosis. The youthful appearance of the breast is best corrected by the relationship of the nipple areola complex to the breast crease or inframmary fold.

I use in consultation, the breast ptosis method as classified by Regnault with modification: Grade 1 ptosis - The nipple areola complex has descend to the level of the inframammary fold. Grade 2 ptosis - The nipple areola complex has descended below the inframammary fold. Grade 3 ptosis - The nipple areola complex has descended below the inframammary fold with no lower pole tissue below nipple.

In general I have found that Grade I can be corrected with the placement of an implant and/or a superiorly placed crescent mastopexy incision. Often a Benelli type mastopexy can be incorporated to reduced the diameter of the nipple areola complex. Grade II ptosis often necessitates a vertical incision with/without a lateral limb extending from the nipple areola complex. Grade II ptosis often requires a vertical component and horizontal component(s) to make the breast appear youthful.

As one can understand from the photograph above in the after picture on the left, the breast appears more youthful based on the relative size of the nipple areola complex and its position relative to the breast crease. Furthermore the breast has been centralized with its take-off no further lateral than the anterior axillary line. This position of the breast on the chest wall facilitates physical exercise. At three weeks post-operatively, I anticipate that the scars will soften and the swelling will subside giving an even more natural and youthful appearance to the breast as time progresses. Full post-operative change and swelling takes approximately 6 months to one year.

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Capsular Contracture Treatment

Capsular contracture symptoms usually begin with the patient noticing a distortion of their breast implant shape or the beginning of an occasional pain around the implant or the breast.

To explain the changes in the shape of the implanted breast with the development of capsular contracture it is important to understand the following:

Most breast implants while they may vary slightly depending upon profile are the shape of a disc. When the lining around the implant starts to aggressively contract symmetrically, the shape that forms is a sphere. Now the breast implant which was once a fixed volume in a defined surface area is now changed to the same volume being compressed into a smaller surface area by the capsular contracture. This change not only distorts the augmented breast, but the augmented breast also becomes firm. This firmness can cause capsular contracture symptoms such as sharp pain, dull pain, pain with movement of the breast, or with exercise. When the capsule implant complex becomes painful, the patient has developed a Baker IV capsular contracture.

Typically in these patients, my preferred method of capsular contracture treatment is total "en bloc" capsulectomy so that the entire capsule and implant contents can be removed in their entirety. Removal "en bloc" allows for an optimal plane with which to attempt implantation.

In the picture shown above, the one appreciates the spherical shape of the hard capsule lining which has compressed the discoid silicone implant. In this case the silicone implant shell was ruptured with the silicone remaining within the capsule.

I will continue to research capsular contracture treatment and prevention.

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Capsular Contracture and Saline Implant Valve Failure

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There are an increasing number of patients who come into my office for consultation regarding capsular contracture pain. Recently, I am seeing more patients come to both the Beverly Hills and Newport Beach offices from the South, Midwest, and East Coast with capsular contracture symptoms.

Frequently these patients present with signs and symptoms related to their capsular contracture such as change in shape of their breast, asymmetry, pain, and more frequently I see women who present with malfunction of their saline breast implants. Occasionally if saline implants have been in place for a long period of time, the shell may undergo “fold flaws" and rupture at the weakest location of the shell.

Most recently, I have seen several cases where a capsular contracture has started to cause breast pain and soon after the patient experiences a deflation of their saline implant. While the leakage of saline does not cause any physical harm to the patient, it is nonetheless very distressing and post rupture may cause more pain to the patient.

In a recent case, as depicted above, I noticed that a small portion of the capsule had grown into the saline valve. While I cannot prove this, I believe that the continued pain experienced by the patient is the adherence of the capsule to the chest wall, muscle, or skin and the mobility of the ruptured implant within the capsule lining.

This motion with exertion, movement, etc. can be extremely painful to the patient and warrant surgical removal and replacement of the mammary prosthesis. More frequently, I am seeing more patients from outside of California who present with either Baker Grade IV capsular contracture or Baker Grade III capsular contracture who also have a malfunctioning of their breast prosthesis. Capsular contracture surgery is frequently performed at both the Beverly Hills and Newport Beach, CA surgery centers.

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Plastic & Reconstructive Surgery Journal Publication

It is truly a great honor to contribute to breast augmentation research and publish in the Journal of Plastic & Reconstructive Surgery with Dr. Malcolm Lesavoy and Dr. Andrew Trussler. Dr. Lesavoy is a great mentor to me and is a pioneer and leader in the field of plastic and reconstructive surgery. Dr. Trussler is the best chief resident I have ever learned from and is well on his way to becoming a leader in academic cosmetic surgery. I am very fortunate to know such great individuals.