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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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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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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