Pocket Reinforcement Using Acellular Dermal Matrices in Revisionary Breast Augmentation

Kaufman and Clark Plastic Surgery, 2220 East Bidwell Street, Folsom, CA 95630, USA

E-mail address: David@thenaturalresult.com

Abstract

Revision breast augmentation to treat implant malposition is fraught with challenges. This article focuses on treatment of implant malposition by using acellular dermal matrices (ADMs) with the intent of creating more reliable and accurate results. The article discusses the use of ADMs in patients with breast implant complications such as bottoming out, lateral implant displacement, or synmastia. ADM is a foreign material, thereby adding potential complications to consider.

Keywords

• Implant malposition • Bottoming out • Synmastia • Lateral implant malposition • Implant problems • asymmetry • Acellular dermal matrix • Revisionary breast surgery

In 2010, close to 300,000 breast augmentations were performed in the United States, making this the most commonly performed cosmetic surgery.¹ By virtue of the sheer numbers of annual breast augmentations performed, a large market for revisionary augmentation procedures exists. The two most frequently encountered complications of primary breast augmentation are capsular contracture and implant malposition.² This article focuses on treatment of implant malposition, excluding capsular contracture, by using acellular dermal matrices (ADMs).

Implant malposition may occur in any one (or a combination) of the four breast quadrants.

Superior displacement (high-riding implants) may result from inadequate pocket creation, insufficient release of the pectoralis major muscle, or secondarily as a presentation of capsular contracture (Fig. 1A).

Fig. 1 (A) Implants high in relation to breast tissue. (B) Double-bubble deformity, in which the inframammary fold (IMF) has been violated. (C) Widely spaced implants as a consequence of a wide sternum and round rib cage.

Medial displacement (synmastia) is almost always an iatrogenic consequence resulting from overdissection of the pocket or selection of implants that are too large.

Inferior displacement (bottoming out) is the most common malposition and presents as an elongation between the nipple areolar complex (NAC) and neoinframammary fold. This malposition may lead to stretching of the inferior breast pole skin, compromise of the integrity of the inframammary fold (IMF) structure, or a combination of the two (see Fig. 1B).

Lateral displacement of the implant is, to some degree, normal with submuscular implants, but excessive lateralization (telemastia) can create a wide separation between breasts (see Fig. 1C). Each of these deformities needs to be understood anatomically to institute proper revisionary surgery.

Anatomic considerations of secondary breast augmentation

Many challenges face the plastic surgeon when considering revisionary augmentation mammaplasty.³ Patient dissatisfaction with the result of the initial procedure and secondary procedures creates unexpected costs and stress for patients who expected acceptable results with a single procedure. Each successive revision is incrementally more challenging, therefore it is crucial that each attempt at revision is done with as much forethought and planning as possible.

It is important to fully understand the anatomy of the primary augmentation failure to properly diagnose and treat the unsatisfactory outcome. Considerations include (Table 1):

• Nipple to sternal notch distance

• NAC to IMF distance

• Location of the current and original IMF

• Breast base width

• Potential presence of capsular contracture

• Plane location of the implants

• Approach location.

Table 1 Considerations for diagnosis and treatment of unsatisfactory outcomes

Measurement	Normal Dimension	Abnormality
Nipple to sternal notch	17–20 cm	Too long indicates the need for superior repositioning of the NAC
NAC to IMF	4–6 cm	Too long indicates the need for a mastopexy to reduce the bottom pole skin or repositioning of the IMF superiorly (for double-bubble deformity)
Location of IMF	Sixth rib	Too low indicates need to reposition the IMF
Base width	Variable	Assists with the selection of implants

The following characteristics of the implants should be evaluated:

When considering revision surgery, it is good practice to review the prior operative reports to learn as much as possible about the initial augmentation (or previous revisions) before undertaking further procedures.

Prevention of deformity following primary augmentation

Before discussing treatment options and strategy for revision breast augmentation, it is important to understand how to prevent the unsatisfactory result. There are important anatomic considerations that the plastic surgeon must recognize and carefully manage during primary augmentation:

• Short NAC to IMF distance. In cases in which there is insufficient inferior breast pole skin, it is important to educate patients about the limitations this anatomic variation presents (Fig. 2A). After augmentation, the inferior pole expands, although it is typically not sufficient for the nipple to be positioned at the midportion of the breast mound. High-profile implants place the point of maximum projection lower on the breast and create more projection for the relative volume. It does this at the expense of sacrificing medial and upper pole fullness, although the trade-off usually leads to a better aesthetic result. Selection of modest-size implants is wise in these challenging cases, and although some surgeons are comfortable with lowering the IMF surgically, I find it perilous (see Fig. 2B).

• Round rib cage. A patient’s skeletal anatomy has a significant role in the outcome of breast enhancement. Implants rest against the chest wall and their projection is perpendicular to a line tangent to the rib cage. Thus, women with round chests (see Fig. 2C) have implants that point radially outward, leading to a widened gap between the breasts and less projection of the implants. In this instance, patient education is again crucial, because patients are more accepting of the outcome when this anatomic variation and its limitations are discussed beforehand. It is harder to satisfy a patient when this is explained after surgery. Wider-based implants are preferred in these patients because they create more medial fullness. Limiting lateral dissection, and even leaving a slip of pectoralis muscle laterally, can help with limiting the lateral shift of the implants.

• Long nipple to sternal notch distance. Many patients with long nipple to notch distances present seeking breast augmentation when they would benefit from a mastopexy. These patients (and some surgeons) think that placing large implants will fill the skin envelop adequately and avoid the increased scarring associated with breast lifting. It is crucial to have a frank discussion with patients who possess long nipple to notch distances, or nipples below the IMF, regarding the outcome without undergoing a breast lift. In these cases, some patients may achieve results that are satisfactory, although this is usually an exception. For borderline cases, sometimes a circumareolar mastopexy is considered. This approach may lead to early revision instead of a revolumized and lifted breast, because patients are left with larger, more droopy breasts. In addition, I have found that patients are uniformly disappointed by the poor cosmetic appearance of the resulting enlarged, distorted, and scarred areolas.

• Pectus excavatum. Just as round rib cages present challenges to the plastic surgeon, so too does pectus excavatum. Pectus excavatum results in a radially inward-oriented breast. In this instance, moderately sized implants are a better choice, because they lessen the kissing-breasts deformity.

• Tuberous breasts, radiation damage, Poland syndrome, and severe asymmetry. Discussing each of these presentations is beyond the scope of this article, but recognition of the deformity, patient education, and creating the proper expectations of outcome are the keys to a satisfied patient (see Fig. 2D).

Fig. 2 (A) Short distance between NAC and IMF. (B) Marked volume asymmetry with vertical height difference between left and right IMF. (C) Round rib cage and widely spaced breasts. (D) Tuberous breast deformity with volume and IMF height asymmetry.

Current treatment options without the use of ADM

Revision breast augmentation for deformity has a long history, although ADMs have only been in widespread use in plastic surgery during the last decade. The treatment of breast implant malposition depends largely on the patient’s anatomy, presenting complaints, desired outcome, and anatomic limitations. This article reviews some of the tools available to help surgeons in the treatment of these deformities. The use of ADM is often complimentary.

• Plane exchange. Subglandular implants are prone to inferior displacement. There is little soft tissue for support and, as breast volume decreases, these implants are more likely to exhibit rippling and unacceptable palpability. Implants in the subglandular plane are also more susceptible to capsular contracture. Removal and replacement to a submuscular pocket may improve a great deal of the presenting complaints. It is debatable whether the prepectoral capsule needs to be removed. However, I find it is necessary to at least score the posterior wall, allowing the pectoralis muscle to expand. It is often necessary to use the inferior capsular wall to extend the reach of the pectoralis muscle and provide additional implant coverage in the lower outer quadrant.

• Capsular flaps. Following primary augmentation, especially in the setting of small breasts with large implants, there is often little soft tissue to work with during secondary procedures. Investigators have described using capsular flaps to reinforce pocket repair.⁴ Although some have found success with these techniques, the use of capsular tissue cannot always be relied upon in the case of diseased capsule because the strength and longevity of capsular tissue are inconsistent.

• Muscle-splitting biplane. In cases of animation deformity, or subglandular bottoming out, a muscle-splitting biplane placement has been advocated.² This technique divides the pectoralis major muscle along its fibers and places the new implant in a partial subpectoral pocket. Superior pole coverage is provided and multiple-layer capsulorrhaphy is used to support the inferior and lateral implant pockets. A great deal of reliance is placed on the inferior capsulorrhaphy, and many investigators find that capsular repairs result in a high rates of recurrence.

• Capsulorrhaphy. Because there is often a paucity of manipulable tissue in the augmented breast, capsulorrhaphy remains a mainstay of revisionary strategy, especially in the setting of full or partially submuscular implants. Although capsular repair is generally technically easy, long-term results may be poor because the deforming forces that created the original deformity remain present and stretch the capsulorraphy, leading to recurrence.

• Neosubpectoral pockets. In the case of implants already in the submuscular plane, creation of a new submuscular pocket above the already present capsule provides the surgeon a fresh opportunity to create a better pocket for the implants. If the capsule is thin or wispy, it is technically challenging to keep the pockets separated.

• Fat grafting. Much interest has developed recently in fat grafting to the breast, and the topic of stem cells is often included in such discussions. There remains a great deal of confusion regarding the safety, efficacy, retention, and regenerative potential in this modality. Fat grafting is espoused by some to provide permanent volume augmentation, to reduce capsular contracture, and to smooth contour irregularities. However, all these are debated on many levels and additional studies are required to provide guidance for community practitioners.

• Mastopexy. If the nipple to notch distance is too long or there is too much inferior breast pole skin, a mastopexy is indicated to lift the nipple to the appropriate position on the breast mound or to redrape the skin as necessary. It is important to assess the implant position during these procedures because the implant can be bottomed out, the breast parenchyma may become ptotic, or both.

Lessons learned from the use of ADM in breast reconstruction

During the last 10 years, ADMs have found widespread acceptance in breast reconstruction procedures, especially during immediate implant reconstruction. By extending the reach of the pectoralis major muscle, ADM allows for a greater degree of expander fill, which offers the advantages of reducing the initial deformity and maximizing the skin envelope. An excellent cosmetic outcome may be achieved because preserved mastectomy skin is optimized for reconstruction.⁵ Expanders can be filled more rapidly, resulting in a shorter time from mastectomy to completion of reconstruction. The use of ADM may enable the creation of a submuscular pocket adequate to place a full-sized breast prosthesis, which allows maintenance of a fuller, thicker pectoralis muscle to cover the superior and medial implant poles.⁶ The use of ADM can also improve soft tissue drapery around devices without resorting to the use of (nonpectoral) muscle or fascial flaps. Total device coverage with the use of combined ADM and pectoralis muscle coverage provides precise control of the pocket dimensions and permits more predictable aesthetic outcomes.⁷

Currently available ADM

ADM products were introduced to provide an additional tool for surgeons when faced with clinical scenarios in which autogenous tissues were inadequate. Currently, both human and animal sources are used to create allograft and xenograft ADM, respectively. Although each ADM manufacturer may have different techniques in processing the tissue, there is a common pathway.

Procuring Tissue

Tissue is procured through live or cadaveric donors or animal sources. The epidermal and subcutaneous layers are discarded during the initial procedure. All cells are removed, leaving only an acellularized dermis. The tissue is subsequently treated in either a disinfectant solution or irradiated, then cut to size and packaged (most ADMs are available in various thicknesses, sizes, and shapes). Differences between various ADMs can be seen in their production: some are lyophilized, some radiated, and some freeze dried. In addition, some products may need to be refrigerated and/or rehydrated.

Selection of ADM

The decision of which ADM to use is often a personal one, because many surgeons prefer a single product line and become comfortable with its performance. Cost is of concern, given that most patients seeking revisionary breast augmentation surgery have already incurred a high expense from the initial procedure, and the surgeon should be conscious of this stressor when offering revision options.⁸ However, it has been my experience that most patients understand that revisions are more complex than primary surgery and each successive revision typically becomes more challenging. For the patient who has already undergone considerable psychological and financial stress from the unsatisfactory result of the initial operation, obtaining an optimal salvage through revision is of primary importance. Therefore, if the surgeon thinks that using a tool like ADM will make for the best outcome, patients will accept a higher cost.

I prefer Strattice™ (LifeCell Corporation, Branchburg, NJ, USA), derived from porcine tissue, for augmentation revision cases requiring ADM usage because of its predictable performance; specifically, the long-term resistance to stretch. This resistance allows accurate intraoperative visualization of the final result. There is some relaxation, but the repair tends to be robust and there is only a slight degree of repair stretch. In contrast, LifeCell’s human cadaveric product Alloderm tends to relax and creates a greater misrepresentation of the final result. In addition, the price of Strattice™ is among the lowest on the market.

Treatment of inferior and/or lateral implant displacement (bottoming out) with ADM

The most common implant malposition is inferolateral displacement. Overdissection during primary implant placement and tissue atrophy over time are the primary causes. The challenge in correction of this deformity is the lack of good quality native tissue to support a repair. Capsular repair alone has a high degree of recurrence and can be unreliable because the capsule relaxes during the recovery period.

Author’s Approach to ADM Placement

I have found that the use of ADM to reinforce the repair is an essential part of producing consistent and long-lasting results. Technically, the procedure I use is:

• Access the pocket and remove the current implant.

• Capsulotomies are performed as indicated.

• I then use a series of inverted 2-0 or 0 Vicryl sutures to repair the capsule and recreate the inferior and lateral borders of the pocket.

• Once this is done to my satisfaction, I place a sterile sizer in the pocket and fill it to the desired size.

• The patient is then sat upright to assess the new pocket configuration in various positions.

• These steps are repeated until I am satisfied with the symmetry and position of the breasts.

• The patient is returned to the supine position, the sizers are removed, and the pockets copiously irrigated with a gentamicin, bacitracin, and cefazolin solution.

• The ADM of choice is prepared as indicated, placed along the capsular border to reinforce the repair, and sutured into position. I place 10 to 12 sutures for each piece of ADM to ensure proper positioning. In addition, I also usually cut darts out of the ADM to allow it to curve along the shape of the implant without buckling.

• Next, a 10-French drain is placed between the ADM and the capsule to avoid seroma formation and to ensure adherence.

• The implants are then replaced and incisions closed in the usual fashion.

Postprocedure Care for ADM Placement for Bottoming Out

• Early in the postoperative recovery phase, patients are placed into an underwire bra for support

• Drains are left in for between 3 and 7 days, depending on output

• During recovery it is important to limit heavy lifting or strenuous activity because the contraction of the pectoralis muscle can tear the capsular repair or disrupt the placement of the ADM

• I ask patients to avoid any pectoralis muscle activities for 2 months, such as push-ups or weight lifting exercises targeting the pectoralis muscles (Box 1).

The use of ADM can provide excellent results in cases of inferior (Fig. 3) and lateral displacement (Figs. 4 and 5).

Fig. 3 (A) Implant malposition and asymmetry after placement of submuscular implants. (B) Result following pocket repair with lateral placement of ADM capsulorraphy.

Fig. 4 (A) Lateral displacement of the left implant with resultant asymmetry. (B) After repair of capsule and repair of lateral and inferior capsule with ADM. A crescent lift was also concurrently performed on the left.

Fig. 5 (A) Lateral displacement of implants following mastopexy augmentation with submuscular implants. (B) After repair using larger implants and repair of lateral pocket with ADM.

Treatment of medial implant displacement (synmastia) with ADM

Treatment of synmastia is particularly challenging. There are a variety of techniques described for repair and, as typically is the case when there are many techniques, none is definitively superior. The goal of synmastia repair is to separate the breast mounds and ensure that the tissue overlying the sternum remains immobile. If the implants are subglandular, then changing planes is usually necessary. If the implants are submuscular, changing to subglandular may be an option. However, I rarely place implants in the subglandular or subfascial space; in the short term, the revision may look acceptable, but my longer-term experience (>5 years) with subglandular implants has shown poor results.

I approach synmastia similarly to the correction of implant bottoming out:

• The implant pocket is accessed

• The implants are removed and the capsular work is performed

• I secure the medial capsule using sutures and evaluate the results of the capsuloplasty using sizers

• Once I am satisfied with the appearance of the temporary implants, I remove the sizers and secure an ADM sheet posteriorly before wrapping it around medially

• Parachute sutures are helpful to ensure that the medial breast skin stays adherent to the ADM

• A drain is placed and the procedure is completed in the same fashion as for bottoming out (see section on the Author’s Approach to ADM Placement).

Postoperative care

When ADM products are used, the postoperative care is not significantly modified from the normal routine. The manufacturers of almost all ADM strongly suggest using drains around the ADM to reduce the rate of seroma formation.

• I typically use drains placed over the ADM to create a negative pressure seal between the overlying soft tissue and the ADM, and with time the ADM will become vascularized. The thought process is similar to care of a skin graft, for which close apposition of the host tissue to graft is of paramount importance for graft take.

• I typically use an underwire bra as soon as the patient can tolerate it, because it provides an external bolster to the fold repairs. It is important to have the new pocket capsule form properly and symmetrically.

• Patients are urged not to lift anything more than 10 pounds for several weeks and to limit the use of chest wall musculature for 2 months.

Most patients are motivated to return to physical training regimens soon after surgery, but they are encouraged to do so with a modified routine. Exercise bicycles, treadmills, and ellipticals are all machines that can be used without invoking the pectoralis muscles. The concern is that, with contraction of the pectoralis muscles, pocket repairs may be disrupted and optimal results sacrificed. Patients understand these limitations and are typically compliant with the postoperative restrictions.

Complications with ADM

ADM is a foreign material, adding potential complications to consider. Two of the most common complications reported in the literature include infection and seroma.⁹

Infection Management

Infection is an uncommon sequela following placement of ADM. However, if signs of infection are present, such as redness, fevers, drainage, pain, or swelling, management is often a challenge. The conventional wisdom is to expeditiously remove both the ADM and implant. Then, after eradication of infection with antibiotics and time to soften the surrounding tissue, patients are advised to return in 6 months for replacement of the implants.

In my experience, most patients resist accepting the necessity of implant removal. Occasional success can be achieved with removal of the implants, copious irrigation, and removal of all ADM, and then replacement with new implants in a single operation. However, this is often a costly misadventure and caution is urged if this approach is undertaken.

Seroma

In normal circumstances, seromas are benign complications. However, the problem is more complex when using ADM. If a seroma forms around an ADM, it often leads to encapsulation of the graft instead of the normal course of integration and vascularization. If the ADM becomes encapsulated, it can not optimally perform its reinforcing function. In addition, a seroma around the ADM increases the probability of infection. When a seroma is present, placement of a seroma catheter drain can adequately treat the problem, but establishing the diagnosis is a challenge. Instead, I have found that placing a drain during surgery, so that it rests on top of the ADM, and leaving it in place for 5 days has eliminated problems with seroma formation.

Case study 1: Implant deformity

This 30-year old mother of 2 had submuscular 330-mL saline implants placed via a periareolar incision 7 years ago. She reported that her deformity was present shortly after surgery but, for various reasons, decided not to embark on early revision (Fig. 6A). Her presenting complaints included dissatisfaction with breast size, desire for increased cleavage, and inferolateral displacement of the implants. Options included upsizing, exchange to silicone gel implants, consideration of right-sided crescent mastopexy, and left implant repositioning with capsulorrhaphy and reinforcement with ADM. In addition, the placement of ADM on the left was considered to provide equal bilateral substrate so the tissues would age similarly.

Technical details:

• Under general anesthesia, the prior incisions were opened

• The capsules were opened and intact implants removed

• Superior and medial capsulotomies were performed as well as radial capsulotomies to accommodate a larger implant

• A series of 0 Vicryl inverted single interrupted sutures were used to perform the capsulorrhaphy

• A sterile sizer was placed to assess symmetry and assist in final implant selection

• Once symmetry was obtained, a 4 × 16 cm piece of Strattice^TM was placed along each capsular repair to reinforce the new position of the lateral and inferior pocket

• The pockets were irrigated with triple-antibiotic solution and drains placed

• New 800-mL high-profile gel implants were placed and incisions closed

• The patient’s NAC symmetry was assessed and a left circumareolar mastopexy was not performed

Fig. 6 (A) Unilateral bottoming out of the submuscular implant. Note the lack of superior pole and the elongated distance between the NAC and IMF. (B) After repair of capsule and placement of ADM. (C) Intraoperative photograph of the ADM placed to reinforce the lateral pocket.

Case study 2: Bilateral implant malposition

This 43-year old woman presented 8 years after her third revision augmentation, with bilateral implant malposition, left Baker IV capsular contracture, severe asymmetry, and synmastia (Fig. 7A). She desired improved symmetry, treatment of her capsular contraction, slightly larger implants, and correction of synmastia.

Technical details:

• Under general anesthesia, the previous periareolar incisions were opened and as much dissection around the capsule was performed as possible

• The capsule was then opened and both implants were removed intact

• A total capsulectomy was then completed

• A series of Vicryl sutures were placed medially, inferiorly, and laterally to define the borders of the submuscular implant pockets

• Sizers were then placed to evaluate symmetry and the effect of the internal sutures

• An external bolster was placed to assist in creating a smooth arc along the pocket borders

• Next, a 4 × 16 cm piece of Strattice^TM was placed along the medial and lateral pocket repairs to strengthen and reinforce the pocket-defining sutures

• A drain was placed and, after triple-antibiotic irrigation, the implants were placed and incisions closed

• The external bolsters and drains were removed 1 week after surgery

• The patient was placed into an underwire bra as soon as the external bolster was discontinued (her results are shown at 4 months; see Fig. 7B)

Fig. 7 (A) Right medial implant displacement, left capsular contraction, and implant malposition following breast augmentation and 2 revision procedures. (B) Result after capsulectomy, pocket repair, and reinforcement with ADM.

ADM for revision breast augmentation: summary

ADM products have been shown to be an invaluable resource in revisionary breast augmentation procedures, validated both in the plastic surgery literature as well as in my own experience.^8,^10,¹¹ It is an ideal soft tissue substitute because of the lack of antigenicity and its ability to become integrated and vascularized into the host. These biologic materials also provide the intraoperative benefit of accurate long-term visualization of results, because ADM are generally resistant to stretch over time (some products more than others). In addition, the material provides strength and consistency that I think are superior to a patient’s native tissue (such as capsular flaps) in providing reliable reinforcement for new implant pocket creation. Although high cost may be a drawback, the overall benefit is worth it because patients can be more assured of a reliable and aesthetically pleasing revision that is preferable to the psychological and financial stress of further revisions. I urge all plastic surgeons to consider this tool in their cosmetic and reconstructive breast practice.

Case study 3: Breast augmentation dissatisfaction

This 32-year old woman presented with generalized dissatisfaction following breast augmentation several years ago (Fig. 8A). She thought that her implants were too far apart, too small, and that her breasts were not attractive.

Technical details:

• Her procedure involved opening the previous inframammary incisions and capsules. Each capsule was thin and wispy.

• The implants were removed and a capsulotomy medially and superiorly was performed, thereby allowing a larger pocket to be created for the new implants to be repositioned superiorly and medially.

• A lateral capsuloplasty was performed to close the inferolateral pocket.

• Sizers were used to ensure that the pocket was properly modified and the results would be consistent with the patient’s desires.

• A drain was placed.

• ADM was sutured in place inferiorly and laterally for pocket reinforcement.

• Silicone memory gel implants were placed and the incisions closed.

Postoperative photographs are shown at 6 months (see Fig. 8B).