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.

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 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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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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Breast Augmentation Consultation & Bra Sizing: The Challenges & The Basics

Breast augmentation consultations and procedures may be challenging when trying to determine post-operative bra size. I have found the bra-sizing system designed by Dr. Edward A. Pechter from Valencia, CA to be the most effective method for successful breast procedures.

The breast augmentation consultation can often bring anxiety to the patient as there are many questions to be addressed or discussed. These variables can range from topics pertaining to the patient (medical conditions, height & weight, bra size, pre-operative breast shape); surgeon (preference for above vs. below the muscle, incision choice); or implant (saline vs. silicone, smooth vs. textured, profile).

Determining bra size in breast procedure consultations creates a common frame of reference for the physician and patient to discuss post operative bra size. The first step in the physical examination is observation. In the observation step, both the patient and I stand in front of the mirror and with the same perspective identify any asymmetries between the breasts. Breasts are more often than not asymmetric with either a discrepancy in breast volume, breast fold position, nipple position, shoulder height, and chest wall asymmetry. After this step of the physical examination we proceed to pre-operative bra sizing.

Bra Sizing: The Basics

The size of a bra is determined by two factors: 1) The Band Size & 2) The Cup Size.

1) The Band Size

Step 1. The band size of the bra is relatively a fixed number determined by the circumference of a woman’s chest. This number can be measured with a measuring tape in inches, just beneath the breasts, in the crease where the band of the bra would be placed.
Step 2. Add five to the number of inches determined from this measurement. For example, if the measured number is 27” then if you add the number 5, the result is 32. Therefore the band size of the bra necessary is 32. If the measured number were 28” adding 5 would result in a 33 band. One quickly realizes when bra shopping that there are no odd number band sizes, so one would try on a 32 or 34 band bra to see which fit best. In this scenario, the 32 bra would be worn on the last of three clasps and a 34 bra would be worn on the first of three clasps.

The band size is relatively consistent in women of adult age as the bony ribcage has completed growing. This number will change to a small degree if a woman gains or looses weight around the chest where the band of the bra would normally be placed. The so called “bra fat”.

2) The Cup Size

I have found the “Size Me Up” system designed by Edward Pechter in Valencia, CA to be the best system for determining cup size. In the “Size Me Up” system, the dome of the breast is measured by starting the measurement from where the breast begins on the side of the chest, passing over the nipple and finishing towards the sternum where the breast ends. The resulting measurement is then compared on the “Size Me Up” chart to determine the cup and bra size.

One point I have learned is that the “cup volume” or “measured breast dome” increases depending upon the band width. That is, a “C” cup represents a smaller volume breast for a woman with a small ribcage (i.e.32 band size bra, C-cup) than a woman with a larger ribcage (i.e. 36 band size bra, C-cup).

In my experience, the best manner in which to predict the post-operative cup size is to determine the pre-operative bra size measurements and base diameter of the patient. The post-operative cup size can be predicted by using these measurements with the volume per base diameter of the breast implant.

While the prediction of post-operative cup size is not exact, I find this step to be helpful, as it facilitates a common frame of reference between the patient and surgeon.

Photograph: Revision breast augmentation. Bilateral Capsulectomy, Conversion of total submuscular saline breast augmentation to dual plane silicone breast augmentation.

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Revision Breast Augmentation: Correction of Capsular Contracture & The Double Bubble Deformity

While I enjoy all aspects of Aesthetic Surgery, correction of capsular contracture and revision breast surgery is particularly enjoyable to me. Not only do I enjoy anatomic and aesthetic challenges of these operations, but also the degree of patient satisfaction is high.

This patient had painful capsular contracture and left breast double-bubble deformity. Correction of this asymmetry was done with bilateral "en bloc" capsulectomy, re-set of the inframammary fold, and change of implant profile.

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