DR. EPSTEIN’S COMPREHENSIVE Breast Augmentation Guide

Anesthesia – General, Sedation or Local?

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Correction Of Lower Pole Stretch / Inferior Implant Malposition

*Individual results may vary

As in treating any other cosmetic deformity, in order to treat this problem, a thorough understanding of the cause is essential to planning proper surgical correction. The following questions must be addressed:

1. Is the deformity all due to stretching of the lower pole of the breast with the implant still in the proper vertical position on the chest (scar remains in the crease)?

2. Is the deformity due to inferior (downward) migration of the crease as evidenced by the scar migrating upwards on the breast?

3. Lastly, could the deformity be caused by a combination of both of the above?

The overall aesthetic result will be more tolerant of simple stretching of the lower pole of the breast (situation #1 above) than it will be if there is true inferior migration of the crease and vertical descent of the implant (situation #2 above) which will result in greater lower pole fullness and less upper pole fullness of the breast.* This is because the top and bottom of the breast mound actually shift downward, where as the nipple-areolar complex (NAC) remains in the same position. Now the NAC will be too high on the breast mound, and a brassiere will fit too low on the breast. This can even create problems with exposure of the NAC above the upper edge of the brassiere, causing considerable concern to the patient – a major wardrobe malfunction!.

Situation #1 rarely requires any treatment because the breast will appear somewhat bottom heavy but the nipple (NAC) will remain in the proper position on the breast mound. There will simply be more fullness in the lower breast and less fullness in the upper breast.

There are situations where the degree of lower pole stretch is too great and correction is desired. This can be achieved by performing a plication of the capsule, the natural scar tissue capsule that forms around all breast implants. In this procedure, the breast tissue is elevated off the capsule and is plicated, or sewn to itself, across the lower breast, shortening the distance from lower breast crease to nipple. This is also known as a capsulorrhaphy (rhaph is latin for “to suture”). My concern about this procedure is that there may be recurrent stretching of the breast. In this case, I like to place a curved sheet of GalaForm surgical scaffold on top of the repair to reinforce the plication, as well as support the lower breast,  somewhat like having an internal bra.

Situation #2 is a different problem altogether. In this case, the skin just below the breast crease has lifted off the chest wall and is now recruited into the breast implant pocket. This will cause the implant itself to move downward on the chest wall. This is a very common occurrence, and fortunately, the amount of descent of the breast crease is usually about one centimeter or less, which rarely will impact the aesthetics of the breast to any significant degree. I have found that most women who have this are not even aware of it when it is this mild. The problem is when the degree of descent of the crease is about 1.5 – 2 cm (or greater). In this case, the aesthetics of the breast is affected significantly. In these cases, one of the first things the patient may complain about is obtaining adequate coverage of the NAC by her bra. This is because the bra is pulled downward by the now lower breast mound. There is also loss of upper breast fullness, causing the nipple (NAC) to appear too high on the breast mound.

The remaining focus of this article will be on the repair of this deformity when the crease has dropped and the implant has shifted downward (situation #2).

The goal of the procedure is to raise the lower breast crease or “inferior fold” back to its original position on the chest. As all my surgeries are performed such that the incision is made in the planned position of the breast crease after surgery, I plan to raise the crease to the level where the scar is.

The patient is marked in the standing position noting the current and desired position of the crease. At surgery, an incision is made through the existing scar and the implant is temporarily removed and placed aside. When you look into the pocket, you will see a glimmering, thin, layer of scar tissue called the capsule. The lower pole of the breast is the thinnest, so there is not much tissue to work with. Somehow, we need to fix the lower breast, which consists of skin, breast tissue and capsule, to the chest wall, which also is covered by the same capsular tissue.

A capsulorraphy is a procedure to suture the capsule from one side to the other to close off some of the pocket. That is what is needed here. However, the problem is that the capsular tissue is thin and doesn’t hold suture well, so the repair might be at risk for failure. I have created a procedure which works fairly well, leaving a solid repair. It is not 100% – the repair can still fail, but it works about 90% of the time. In this procedure, I cut through the capsule to enter the breast tissue itself and the fascia (connective tissue) over the chest wall rib muscles on the other side. Using a special way of suturing, I bring the breast tissue to the rib muscle fascia so that the raw tissue can heal together. This is very different than just suturing smooth capsular tissue together. I have been very happy with the repairs this far. After surgery, the lower breast looks a little flattened by the breast crease, but this auto-corrects in about four weeks. After surgery, there is a little tenderness for a few days over the ribs where the sutures were placed, but this is easily managed with tylenol or advil.

Recently, I have been offering patients one additional option for repair. After performing the repair as described above, I place a small piece of GalaFlex over the repair to add an extra layer of strength and support while it is healing. The GalFlex will last for about one to two years and during that time the body will actually lay down about three millimeters of extra scar tissue where the GalaFlex was placed, giving a more permanent solution to the repair. While this does add an extra time and materials, and therefore extra cost to the repair, I believe that it is worth it as a better repair can be performed, hopefully reducing the risk of repair failure and need for yet another operation. No method of repair that i am aware of is guaranteed to work 100%, but I have had good results with these methods.

To see several examples of correction of this problem, click here.

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Sections – Implant malposition/bottoming out of the breast

Sections – Revision of Breast Augmentation

Chapters – Breast Augmentation Guide

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