A Q & A with Jason N. Pozner, M.D., F.A.C.S.
What are the main reasons patients seek revision breast augmentation procedures?
Previously, capsular contracture, implant rupture, and size were the reasons most women sought revision breast augmentation. However, today many patients tend to complain about shape and skin texture abnormalities following subglandular saline augmentation.
What are the primary benefits of submuscular conversion?
Conversion to submuscular implant placement provides four main benefits:
A well vascularized cover
Separation from the breast parenchyma
“Padding” that prevents implant palpability
Framework that prevents excessive inferior descent of the implant
More specifically, what type of patients typically seek submuscular revision augmentation?
Patient seeking reaugmentation following subglandular augmentation falls into four broad categories that have considerable overlap.
Caegory 1- Size Change
Patient with adequate tissue coverage seeking size change often request submuscular conversion. Although there are no studies to verify it, in my experience there is considerable evidence that submuscular placement decreases capsule rate and implant palpability.
Category 2- Palpability and Ripping
Palpability and rippling are usually due to inadequate tissue coverage and can be compounded by type of implant used (i.e., textured saline). Submuscular conversion will improve upper pole and medical rippling but will not usually correct lateral rippling. Submuscular conversion with smooth silicone implants may be needed if lateral rippling is extreme.
Fig 1 Preoperative Preoperative Postoperative
Subglandular saline implant with superior After conversion with mentor
Pole and lateral rippling smooth silicone 800 cc high
Category 3- Ptosis, Shape, and Position Changes (Fig 2)
Breast Malposition-patient with subglandular implants, especially after multiple pregnancies, often present with grade three pstosis and the “rock in sock” phenomena. Submuscular conversion with mastopexy offers some advantage for long-term support.
Implant Malposition- patients may have misplaced subglandular implants. During consultation a “tilt test” is performed by having patients sit in a power chair. The chair is then lowered to assess the degree of lateral implant movement. Submuscular conversion in itself will improve superiorly and medially displaced implants, but capsulorrhaphy is needed in addition for lateral or inferiorly displaced implants.
Fig 2 Preoperative Postoperative
Subglandular 275 cc with dropped left and failed previous repair. Exchanged with conversion for 400cc smooth moderate profile silicone with capsule repair.
Category 4-Cacpsular Contracture (Fig 3)
In my experience, submuscular conversion with capsulectomy appears to improve recurrent contracture. It is important to consider nipple areolar viability in extremely thin-skinned women in which Capslectomy and mastopexy is performed simultaneously.
Fig 3 Preoperative Postoperative
Subglandular saline with Baker 3 contracture. Exchanged the conversion or 425 cc smooth saline with Benelli.
What’s involved in your patient evaluation process?
During patient evaluation, a determination is made regarding the breast pocket dimensions and position, implant size, skin dimensions and nipple position. Both the patient’s and surgeon’s input is important to determine the best surgical plan. For example, a patient with capsular contracture may need a larger implant or mastopexy with a smaller implant after capsulectomy.
What surgical technique do you prefer?
Ideally, an aereolar approach is used, although an existing inframammary incision may be used if mastopexy or full caspsulectomy is not needed. If capsular contracture is present, full capsulectomy is performed. With no siginifigant capsular contracture, the subglandular pocket is opened and the implant is removed. If the fold is to be lowered or remain constant, the capsule is removed from the pectoralis major muscle. The anterior capsule is scored and brushed with a electrocautery device. Partial capsulectomy (at least) is always performed to allow the tissue to heal without serroma or excessive scarring (Fig 4). The pectoralis major muscle is elevated and divided. The muscle is then plicated to the anterior tissues, usually at the level of the superior areola with several 2-0 Vicryl sutures. Sizers are placed to determine size and pocket shape. Drains are placed in all Submuscular conversions. After the implants are placed, the patient is brought to a seated position and symmetry is assessed and corrected. If no mastopexy is indicated, the wounds are closed.
Are the special considerations that must be considered during surgery?
If the inframammary fold needs to be elevated, a capsule flap is elevated from the pectoralis major muscle prior to elevation. The inferior capsule is excised and the tissues closed. The capsule flap is then sutured to the anterior tissues to reinforce the inferior tissue placation.
Overdissection of the medical pocket may create symmastia or excessive cleavage. IN such cases, medial capsulectomy with closure of the overdissected pocket and creation of a submuscular pocket is performed. Postoperative taping and support are essential.
For lateralized subglandular implants, the lateral pectoral attachments are preserved if possible, and the overdissected tissue is corrected with partial capsulectomy and suture of the cut capsule ends.
After submuscular conversion is complete, the skin is tailor tacked with silk sutures to gauge areolar position and the degree and/or necessity of skin excision. Saline implant fill tubes are then removed at the end of the mastopexy.
What breast implant do you prefer for this procedure?
I prefer smooth round implants. A revision augmentation qualifies the patient for silicone gel implants; however, saline implants can be used if the patient prefers. Postoperatively adjustable implants are useful when there is significant asymmetry or insufficient skin.
Previous conversion with failure to remove subglandular capsule. Note the muscle below and the thickened capsule above.
About Jason Pozner, MD
Jason Pozner, M.D., F.A.C.S., can truly claim aesthetic surgery and skin care as his life’s work. The son of a successful health spa and diet center physician in New York, Dr. Pozner is certified by both the American Board of Plastic Surgery and American Board of Surgery, and is a member of the American Society of Plastic Surgeons, the largest and most prestigious organization of board-certified plastic surgeons in the world.