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1 Submitted by Michael Higgs: May 11, 2007

This 31-year-old mother of three (Fig. 70.1 and 70.2) had bilateral 335 mL, ultrahigh, smooth, cohesive gel (PIP) implants through inframammary incisions, 1 cm below the inframammary creases, on 7th March 2007. Because she was worried about capsular contracture and had read submuscular was better, I changed the original preoperative plan from subglandular to submuscular. The surgery was unremarkable, and the inferomedial origin of both pectoralis major muscles was crushed and divided. Postoperatively she had a little surgical emphysema on the right and was slower than usual with arm movements.

Fig. 70.1
figure 1

Preoperative patient

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Fig. 70.2
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Breast chart

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Both implants were higher than I wished, worse on the left, and she has worn a breast retention strap initially over both breasts and more lately in a figure of eight over the left breast as the right became lower. Postoperative photos (Fig. 70.3) are at 3 weeks before the right side improved.

Fig. 70.3
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Three weeks postoperative

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I have told her we should not make a decision about revision before the 3-month mark and sent her away with the strap for a further month. She was keen to massage the left breast, and I have certainly had another patient who improved her symmetry with massage (she had saline implants per axilla). I think this would do no harm but am skeptical of any improvement.

I will be grateful if you could review pre- and postoperative photos and the breast chart and comment on:

  1. 1.

    Would you revise?

  2. 2.

    How long would you wait before revision?

  3. 3.

    Would you revise just the left or both sides?

  4. 4.

    Would you just deal with any restriction of the pocket on the left to bring the implant down in the submuscular pocket?

  5. 5.

    Would you change both implants to subglandular?

Do you have any other comments? Thanks for your help.

Shiffman

Implants this high will usually not respond further after a month of upper breast compression.

I would recommend changing to a subglandular position and use polyurethane-covered prostheses. That would reduce the likelihood of capsular contraction. The submuscular space can be electrocoagulated or sutured, and the edge of the pectoralis major sutured down so that the implant does not slip into the old pocket space. I do not like to do a capsulectomy of the old pocket since this increases the risk of bleeding and is unnecessary. Make sure virgin tissue is between the implants and the closure of the edge of the pectoralis.

Higgs

When seen at 3 months (Fig. 70.4), there had been some improvement, and the implants were soft, both Baker grade 1. The asymmetry was noted to be similar to the preoperative situation. No revision was performed, and the patient did not return for review at 1 year.

Fig. 70.4
figure 4

(a–c) Three months postoperative

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