Breast Reduction Surgery

Breast reduction surgery is a common breast procedure that can provide great patient satisfaction. Patients who desire breast reduction surgery commonly state pre-operatively that they have back pain, shoulder pain, neck pain, and/or difficulty completing exercises. Not only does breast reduction surgery reduce the volume of the breast, it also places the breast in a more stable position so that the weight of the breast does not have the same impact on the neck, shoulders, and back.

Mastopexy Surgery

Mastopexy surgery is one of the more common procedures as women tend to age. As women age, the nipple areola complex tends to drop below the level of the inframammary fold or breast crease. When the breasts sag, this is called "ptosis". The only way to correct breast ptosis is to perform a lift procedure. The more standard lift pattern is called a "Wise" pattern or "T-lift" pattern.

It is often common for women to desire a breast lift without additional volume placed. That is, a breast lift without the placement of an implant. The recovery period for this procedure tends to be relatively short and associated with very little pain post-operatively.

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Capsular Contracture Surgery

Capsular contracture can be common in patients who have undergone breast augmentation. There are several steps that one can take to reduce the risks of capsular contracture in the future. At the time of capsular contracture surgery, we often take a culture of the fluid from the breast pocket. The fluid is sent off to the lab to determine if there is an underlying bacterial cause for chronic inflammation and capsule formation. Once the cultures have determined to be negative and/or any bacterial colonization is treated with an appropriate course of antibiotics then patients may be given a Medrol dose pack to reduce the risk of capsule formation. 

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Mastopexy Augmentation

Mastopexy augmentation procedures are common procedures. Patients who present for a mastopexy augmentation are typically patients who have had several children and have breast fed or who have lost weight for a variety of reasons. The mastopexy augmentation operation is a complicated one that requires careful planning. The operation is essentially two operations in one. The first part involves placing the implant and the second part involves tightening of the skin. 

The mastopxey augmentation operation differs from the standard breast augmentation in that there is significantly more healing that is required after the mastopexy augmentation. I tell the mastopexy augmentation patients that the overall healing time and time to settle takes at least 6 months to one year. 

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Revision Breast Surgery, Capsular Contracture Surgery

Capsular contracture of the mammary prosthesis and breast construct can occur for a variety of reasons.When performing capsular contracture surgery, it is important to appropriately select and create the appropriate pocket for the implant. Patients are often placed in a sports bra for 4 to six weeks to allow the breast pocket to heal well without any additional trauma.The final implant position and shape can take anywhere from six months to one year to completely settle in.



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Capsular Contracture Surgery

Capsular contracture surgery is common. When a breast implant is placed in the body, the body always forms a lining around the breast implant. Occasionally, the lining can form aggressively and contract. When the lining begins to contract aggressively, the implant starts to displace superiorly where there is less resistance than against the fold. Often the lining contracts against the muscles and the ribs, which can cause pain. Typically, the shoulder girdle on that side begins to get tight. Patients often complain of chest, shoulder, and neck pain.

Capsular contracture surgery often requires release or excision of the capsule. The capsule often adheres to the underlying pectoralis major and pectoralis minor muscle. The capsule is often excised or scored in this area to allow the shoulder girdle to open up. Often, after surgery, patients not only experience an improvement in their overall breast contour, but also in their overall pain. 

Capsular Contracture Surgery

Capsular contracture can occur in patients who have breast implants. While there can be many reasons to have capsular contracture, I find that the more common reasons tend to be 1) history of hematoma or undetectable hematoma, 2) history of previous infection or subclinical infection, 3) long duration of implant placement, 4) patient specific factors (i.e. prone to keloid, hypertrophic scar, capsular contracture, etc.).
In patients who have a history of recurrent capsular contracture, despite previous capsulectomy, I have added to my management plan the following: At the time of capsule surgery, the implant is removed and the implant pocket is cultured. Post-operatively, the patient is placed on Keflex if able to tolerate, or clindamycin if there is a cephalosporin allergy. If the culture result is a bacterium not sensitive to Keflex or Clindamycin, then an antibiotic is chosen to fit the appropriate bacteria.


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Mastopexy

Mastopexy and breast reduction procedures are common. Patients often want to have their breasts lifted to give a more youthful appearance to the breast. The ptotic or "sagging" breast tends to have the nipple areola complex below the level of the inframammary fold. The breast lift procedure is designed to lift the nipple areola complex to a more youthful position above the inframammary fold. Often the breast can be reduced in size at the same time as a mastopexy procedure. This tends to alleviate any shoulder pain, grooving, and trapezius muscle hypertrophy.

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Capsular Contracture Surgery & Revision Breast Surgery

Capsular contracture surgery and revision breast surgery are some of the more common aesthetic procedures performed in our practice.

Capsular contracture is common in patients who have had mammary prosthesis in for over 10 to 15 years. Over time, as the breast capsule contracts, it tends to exert pressure on the underlying breast implant or mammary prosthesis. The mammary prosthesis then tends to reposition itself upwards, as there is less resistance "up" then against the fold inferiorly.

Capsular contracture surgery is performed under a general anesthetic and can take approximately 2 to 3 hours depending upon procedures performed to the breast.

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Capsular Contracture Surgery

Capsular contracture surgery procedures are common when breast implants have been in for over 10-15 years. Removal of mammary prosthesis and capsules involves a surgical procedure requiring general anesthesia.

Following surgery, patients are required to wear a support bra, such as a jogging bra or other bra with significant support. This should be worn 24 hours a day seven days a week for 4 to 6 weeks. Patients often find an improvement in pain following the removal of their mammary prosthesis.

Superior Medial Pedicle Reduction Mastopexy

The superior medial pedicle reduction mastopexy allows for consistent removal of breast tissue from the lateral region of the breast. Often the breast tissue that is directed lateral to the anterior axillary line can get in the way of performing different types of physical activity. The superior medial pedicle allows the operating surgeon to maintain the superior medial fullness to the breasts. It is helpful to limit the length of the inferior limbs of the mastopexy pattern to maintain a lifted appearance to the breast.

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Capsular Contracture Surgery

 

 

Capsular contracture surgery is common in patients who have had breast implants in for a long period of time. While implants can last several years without having the need for revision, when implants have been in for over 20 years or more, the lining that the body produces around the mammary prosthesis can begin to contract.

When the lining contracts, the surface area around the implant continues to decrease. As the surface area decreases, the volume around the implant remains fixed. This causes the implant and lining construct to become hard. As the lining contracts, the implant tends to move superiorly where there is less resistance. Correction of this involves removing both the implant and the lining around the implant and the placement of new implants.

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Mastopexy Augmentation

Mastopexy augmentation and revision mastopexy augmentation are some of the more common operations performed in our office. We frequently see patients who have had implants placed several years ago and who have now lost weight or who have had several children. The result is a breast shape that has become ptotic as well as a loss of volume.

Correction of the breast shape and volume often requires the placement of an implant as well as a mastopexy procedure or breast lift procedure to improve the appearance and position of the nipple areola complex. Patients are often very satisfied after these procedures as their breasts appear more youthful.

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Breast Reduction and Mastopexy Surgery

Breast reduction surgery is a common surgery. Patients who wish to undergo breast reduction surgery typically mention that they have pain in their neck and shoulders as well as their lower back. Occasionally when patients have large breasts, they have rashes in their breast creases. After breast reduction surgery, not only are the breasts lighter and is pain relieved, but also the breasts have a more natural and better aesthetic appearance.

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Capsular Contracture Surgery

Capsular contracture surgery involves removing the breast capsule that has formed over many years and then place a new breast implant of similar or different dimensions or size. Typically recovery from capsular contracture surgery can be quicker than the recovery from the original breast augmentation procedure. The goal of capsular contracture surgery is to remove the painful capsular contracture and allow the breast to re-drape or re-expand over the new breast implant.

Synmastia Correction & Capsular ContractureSurgery

Synmastia occurs when a breast implant begins to cross the midline towards the sternum. This is often upsetting to the patient and is often even more accentuated when wearing a bra or low cut shirt. Correction of synmastia can be challenging for both the patient and surgeon.


Appropriate steps in synmastia correction require accurate diagnosis of the problem. Synmastia can occur from either an overly large pocket medially above or below the pectoralis muscle. Quite commonly this can be more obvious by an implant with too large a base diameter for the rib cage or thorax. It is also common for the patient to have a capsular contracture at the same time.

Patients often ask me what they will look like post-operatively from capsular contracure surgery in terms of bruising. I often tell patents that swelling is normal and can be expected for quite some time following capsular contracture and synmastia surgery. The photo above shows and early (5 day) post-operativel result. I tell patients that early post-operatively the implants and breasts take on a globular shape which improves in almost regular intervals at one month, two months, four months, six months, and then finally at one-year.

Capsular contracture surgery is commonly performed either because the capsules are causing a significant amount of pain to the patient or the capsules are starting to distort the breast shape or size.

Typically capsular contracture surgery tends to restore a normal contour to the breast. Patients often ask me what they will look like after surgery in terms of bruising or swelling.

I often tell patients that during capsular contracture surgery, they may require drains post-operatively to removed fluid from the breast pockets. The drains typically exit just lateral to the breast. Drains can be left in place from one to 5 days post-operatively. The patient in the photo above is an early (5 days) post-operative result.


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The Neo-Supracapsular Pocket for Revision Aesthetic Breast Surgery

Having great interest in Breast Reconstruction, Aesthetic Breast, and Revision Breast surgery has afforded me ample opportunity to study the manipulation of the infra-mammary fold and its relation to the perception of breast symmetry.
Two determinants of breast symmetry in photographs or when the patient looks in the mirror is the position of the nipple areola complex (NAC) and the relative distance/inter-relationship between the distance of the NAC to the infra-mammary fold. I have found that the creation of the neo-supracapsular pocket allow the operating surgeon great opportunity to change fold position while maintaining a natural breast contour.

Lifting the infra-mammary fold can be quite challenging for the surgeon and frustrating for the patient if not positioned correctly. If the folds are mal-positioned, then the bra does not contact the base of each breast at the same location which is often frustrating for the patient. Correction of the fold position alone can often change not only the position of the NAC, but also the position of the NAC in relation to the center of the implant which can make the asymmetry worse. Therefore to optimize breast symmetry the surgeon will have to calculate the distance from the fold to the NAC and try to adjust each breast to reach a common length. At the same time, similar or dissimilar implants must be selected to optimize volume symmetry as well as centralize the NAC on the implant base.

I have found great utility in the use of the "neo-supracapsular" pocket, not previously described for the correction of this deformity and in breast cancer reconstruction. The neo-supracapsular pocket allows the surgeon the opportunity to correctly position the fold, yet also have control of the contour of the breast without creating dimpling, blunting the fold, or restricting the NAC to fold distance.

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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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