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reasons for redo are uncommon and include infection Technique
and bleeding, but both may necessitate urgent attention All procedures are performed under general anesthetic
or an emergency surgery. The late complications with full muscle relaxation and as a day case. Patients
[3]
are more common and do not generally constitutes were placed in the supine position with arms abducted
emergency procedures. These late complications include in less than 90°. Inframammary crease was used for the
[1]
capsular contracture, change for implant size and shape, pocket access.
implant rippling, asymmetry of shape, implant rupture or After explantation of the device, pocket was examined
ptosis. Revision surgery for these complications is either for its dimensions and extent and nature of the capsule.
performed alone or in combination, depending on the In grade 1 or 2 capsular contractures, only lower pole
presentation. Revision surgery in these complications capsulotomies were performed. Breast presenting with
often requires a change of implant. These complications advanced capsules, partial or complete capsulectomy
and their corrective surgery can often be challenging for was performed. The next step was to identify Pectoralis
a surgeon and requires a detailed history of previous Major and marked by light scoring on the posterior layer
surgery, thorough examination, patient’s wishes for a of capsule, starting from the junction of the middle
desired results and a well thought, clear and meticulous and lower third of sternum medially and going up and
plan. Patients presenting with these complications may laterally to the anterior axillary fold. This line of the
have an associated ptosis that may require simultaneous muscle split was transposed and marked anteriorly by
mastopexy using either periareolar, vertical scar, wise scoring the anterior layer of the capsule, this scoring
pattern markings or their modifications. The pocket
[4]
for implant replacement can be subglandular, partial should ideally be at or just below the nipple level in the
submuscular, subfascial or muscle splitting. Multiplane midline.
[5]
internal mastopexy (MIM) or use of more than one pocket Pectoralis split was commenced medially at the junction
for augmentation and the internal mastopexy using an of the middle and lower third of the sternum. Pectoralis
inframammary crease has been described and was used muscle is pinched and lifted off the sternal margin using
in selected patients. The technique allows avoidance of Gillis toothed forceps, and a small incision is made using
scar in the border line ptosis and especially suits those cutting diathermy. The incision should be large enough
patients who are not interested in obvious scarring to allow index finger, and once the finger is inserted,
associated with conventional nipple mobilization. The submuscular dissection was performed using index
technique was used for primary cases with a limited finger extending up to the 2nd intercostal space and to
experience in revision mammoplasties. The current the anterior axillary line laterally. Once the submuscular
[6]
article describes a larger experience in selected patients dissection is completed, incision is usually large enough
who had their initial augmentation mammoplasty in allowing the breast retractor to be inserted with its distal
subglandular pocket. The technique allows an addition to end pointing towards anterior axillary fold. Muscle split
the armamentarium of surgeons for patients who present begins medially using cutting diathermy, and once the
for revision surgery with minor to moderate ptosis split gets closer to the anterior axillary fold, the dissection
following augmentation in subglandular pocket. is slowed down. Here, coagulation of the muscle is
performed before splitting or cutting it up further. The
METHODS maneuver avoids inadvertent bleeding resulting from
damage to thoracoacromial axis branches.
A retrospectively collected data were analyzed in the Once pectoralis split is completed, the lateral
Excel Spread Sheet (Microsoft). Between January 2008 capsulotomy is extended upward to join the lateral
and October 2013, 25 patients had MIM following their extent of muscle split. The lower border of the upper
augmentation mammoplasty in subglandular pocket. split pectoralis is now stitched to the breast envelope
Relevant data of 25 patients who had their revision below the marked and scored anterior capsule using 2-0
surgery in multiplane pocket was further analyzed. Six Vicryl interrupted stitches vicryl (Ethicon) [Figure 1a-c]. The
months postoperatively, patients were asked whether level at which the anterior capsule is stitched to the lower
they were very satisfied, satisfied or dissatisfied with the border of upper split pectoralis depends on the degree
outcome of the surgery.
of ptosis but should not be less than 2 cm [Figure 1a].
Examination Hemostasis is achieved, and a preoperatively selected
All patients are examined in standing and supine position. implant is placed in its new pocket. Before wound closure
Supine position allows any excess pocket extension in and once the new implant is in place, the flat of the hand
lateral dimension. Breast ptosis with or without upper is run over the skin envelope sliding the skin inferiorly
and medial quadrant rippling is an indication for the over the mound of the implant. Creation of a crease or
conversion technique. Lower and lower lateral skin fold, due to an internal stitch placed too low inside the
envelope rippling is unlikely to be improved by muscle skin envelope, is an indication of replacing the stitch
splitting conversion or any other submuscular technique. to a little higher position. The head end of the table
Degree of capsular contracture is noted, and information can also be raised to confirm the fold, which depends
is gathered about the size and profile of the existing from the anchoring suture inside and can also be felt
implants. by doing a bimanual digital examination using index

Plast Aesthet Res || Vol 2 || Issue 3 || May 15, 2015 121