Incorrect Development of the Pocket at the Time of Surgery
Most cases of implant malpositions are due to factors that are beyond the control of the surgeon and the patient. Well, somewhat. In other words, the implant pocket was created correctly, but tissue factors such as stretching and thinning, changes in the relationship between the breast tissue and the underlying pectoralis muscle (for submuscular cases), gravity, lactation, aging and probably some other factors I’m not listing here cause changes in the breast with time. This happens naturally to some degree in every patient. Breast implants rarely look “natural” the way they go in. The surgeon relies on a certain amount of natural tissue changes such as stretching to allow the breasts to look good. This was previously discussed in the section “Things We Cannot Control: Wound healing, tissue stretch and gravity.” This takes four to twelve months depending upon the elasticity of the tissue at surgery. If breasts never changed after augmentation, 99% of augmented breasts would look misshapen and distorted, and women would not be so happy with their results. Fortunately, a certain amount of change does occur naturally. There is one way I believe that surgeons (and patients) can help to minimize implant malposition, and I am referring to that due to lower pole stretching. By not exceeding the ideal sized implant for a given breast, the amount of weight on the breast is reduced, and thus less stretching and tissue damage will ensue. Maybe the woman won’t get exactly the size she wants in some cases, but who wants to undergo a second surgery needlessly, or worse yet, create an uncorrectable deformity? Given that there is a certain amount of unpredictable breast stretching that will occur with every augmentation, there is always a risk of implant malposition. This risk is rather low when choosing an implant that properly fits the breast. When selecting an implant that is excessively large for a particular breast, the risk of implant malposition increases considerably.
However, sometimes an implant malposition occurs that is entirely iatrogenic (caused by the doctor). Sure, some of us surgeons like to explain away our failures and disappointments and blame it on the patient’s tissues, but this is not an example of this. As an aside, it is much better to take the time with the patient to explain to her that her tissues are severely compromised and to routinely warn all patients about factors out of the surgeon’s control like tissue stretching, rather than have to make an excuse after surgery and make the patients tissues the scapegoat. What I am talking about here is simply an incorrectly dissected pocket. The patient isn’t moving on the operating table, so it must be the surgeon at fault if the pocket is incorrectly dissected at surgery. If you have a 10 cm diameter implant, then you want a 10 cm diameter pocket and you want the center of that pocket to be after surgery just where you planned it to be before surgery.
What are the causes of an incorrectly dissected pocket?
1. Incorrect placement of preoperative markings
Plastic surgeons love their magic markers. We love to draw on our patients. Actually, drawing on a patient is in many cases absolutely essential to obtaining an optimal result. When you mark a patient in the standing position, then you know where things need to be when the patient is lying down, at which time the relationships between structures change due to gravity, the force of the operating table upon the posterior trunk tissues, etc. So markings are to a plastic surgeon the way an instrument panel is to a pilot flying at nighttime. If a pilot is flying in total darkness and his instruments give the wrong readings, his flight plan is doomed to failure. Same thing here. If the markings were placed incorrectly prior to surgery, then they will be of no use during surgery. Furthermore, their presence will give the plastic surgeon a false sense of security when performing the procedure. This is probably not the major cause of the errors in pocket dissection.
2. Improper dissection of the pocket during surgery
This is a more likely scenario. Let’s look at how most plastic surgeons make the pocket. I will take the example of a submuscular placement of an implant using an incision in the lower breast crease, but you can extrapolate the same concepts equally to subglandular placement through a transaxillary (armpit) incision, or periareolar incision (around the nipple/areola complex).
To make the pocket in the case described above, an incision is made in, or below the natural breast crease. The incision is deepened to the level of the chest wall. The surgeon then identifies the lower edge of the pectoralis muscle and lifts the lower edge of the muscle off the chest wall. Now the space lying between the underside of the muscle and the top surface of the chest wall is entered. There is just thin, filmy tissue here under the center of the muscle which separates very easily, giving access to the center of the pocket. However, the surgeon must extend this pocket to the sides and top of this area, where the tissue is more adherent. The technique used to separate this tissue and further develop the inner and outer sides, and top of the pocket makes all the difference in the world, not only in terms of the amount of (or lack of) discomfort and ease of recovery, but also in terms of the accuracy of the pocket dimensions and location upon the chest wall.
The way most surgeons make the pocket is as follows: After the lower edge of the pectoralis muscle is identified and detached from the chest wall, a large, blunt instrument called a “dissector” is introduced into this space. The dissector is then firmly (and I mean FIRMLY!) pushed upwards towards the collarbone, medially towards the breastbone, and laterally towards the arm and back (This is called “blunt dissection”). This instrument does a great job of creating a pocket for the implant, but there are two problems here. First, the muscle is stretched and ripped from the chest wall, creating a lot of bleeding and inflammation. And the best part is the way this metal dissector bangs across each of the ribs as it is moved upwards and side wards for a few minutes on the chest wall. Talk about pain! Is there any wonder why recovery from breast augmentation is so unpleasant? The other issue is that with all this pushing against the resistance of the tissues, there is absolutely no precision in creating the borders of the pocket, even if you have superimposed markings on the breast. It is not uncommon to over dissect a pocket, which is not all that easy to fix at surgery and is much better not to have occurred in the first place. Also, the pocket can be under dissected, but hopefully, this will be recognized and easily remedied after the implant is placed. Of course, extra time is needed to repair any over dissected areas and to stop all the bleeding. Is there any wonder why the revision rate and capsule contracture rates are so high with this technique?
So what do I do differently here? Simple. No blunt dissection. I have the markings on the skin surface guiding me as to what the borders of the pocket should be. Now, using special breast retractors that I developed (to see them, click here), I can gently lift the breast and muscle tissues from the chest wall and separate them as atraumatically as possible using electrocautery. I can see very easily when I have dissected enough of a pocket to fit the implant, can control any little blood vessel that tries to ooze, and reduce surgical trauma to an absolute minimum. Typical blood loss is only a few cc’s per side. No banging on the chest wall, no tearing of the muscle. The need for surgical revision due to incorrect pocket dissection is all but eliminated!
Too see how I develop the pocket for the implant, watch the video below:
This next video is a compilation of four different surgeons performing breast augmentation surgery on YouTube. Note the use of a finger and other devices to rip, tear and pull the breast from the chest wall.