Capsulorrhaphy for Revisionary Breast Surgery

Paul E. Chasan, MD; and Cameron S. Francis, BS

Background
Despite more than 3 million breast implant surgeries performed to date, the common sequela of implant
malposition is a problem to which little attention has been paid in the literature. It can be treated predictably and relatively
simply with capsulorrhaphy and mirror-image capsulotomy. Additionally, capsulorrhaphy can be used to reduce the size
of the implant pocket when changing to a smaller implant.
Methods: Several capsulorrhaphy techniques have emerged that allow a more precise result with less effort. In almost all
cases of implant malposition, a mirror-image capsulotomy was performed to decrease the tension on the capsulorrhaphy
repair. Silicone gel–filled implants were placed in all cases.
Results: Seventy-five patients underwent capsulorrhaphy for implant malposition or implant size reduction between May
2002 and March 2006. Of these patients, just under half (49%) had an accompanying mastopexy. Excision of capsular tissue
and prolonged taping of the breasts were found not to be necessary. Average follow-up was 21 months; no complications
were reported.
Conclusions: The current technique of capsulorrhaphy and mirror-image capsulotomy has demonstrated satisfactory
improvement in implant malposition, without the need for excision of capsular tissue or prolonged taping. Patients did
report that their postoperative discomfort was greater than anticipated. (Aesthetic Surg J 2008;28:•••.

 

More than 3 million breast augmentations have
been performed in the United States to date.
Implant malposition can be a common occurrence
after breast implant surgery, yet there is little
attention paid to addressing this problem in the literature.
In addition to correction of malposition, there are a
significant number of patients who wish to have their
implants changed to a smaller size while retaining superior-
pole fullness. By placing a smaller implant into an
existing larger pocket, projection and superior fullness
are diminished and lateral displacement occurs on
recumbency. Since our last publication on this subject,1
several modifications were made to make the procedure
more predictable and easier to perform. Capsulorrhaphy
remains an effective method to recontour the shape and
size of the breast implant pocket, resulting in a better
shape and appearance of the breast.

 

Methods
Examination of a patient seen for revisionary breast surgery
requires three additional assessments beyond those
that are standard for primary augmentation. First, the
patient is examined and photographed in the supine
position to evaluate lateral displacement and asymmetry.
Second, the relationship of the areola to breast mound is
assessed during simulation of capsulorrhaphy by digital
pressure, because this relationship may change dramatically
after capsulorrhaphy. Such cases may necessitate
areolar repositioning. For example, a lateral capsulorrhaphy
with a medial capsulotomy can create a relative lateral
displacement of the areola, whereas an inferior
capsulorrhaphy with a superior capsulotomy can result
in relative inferior positioning of the areola requiring a
mastopexy. Finally, it is important to clarify the plane
(subglandular or subpectoral) in which the implant lies
to determine whether pocket repositioning will be
required during the surgery. Generally, the current indications
for pocket repositioning from subglandular to
subpectoral are wrinkling (especially medially) and
recurrent capsular contracture.
Immediately before surgery the patient is marked in
the sitting position. Simulation of the capsulorrhaphy is
performed digitally and marked with the patient in both
the sitting and supine positions. In almost all cases of
implant malposition, a mirror-image capsulotomy will be
performed to decrease the tension on the capsulorrhaphy
repair (Figure 1). General anesthesia is preferred.
The inferior periareolar incision is usually the approach
of choice. Once the implant has been removed, the mirror-
image capsulotomy is performed. With a balloting
technique, digital pressure is applied to the outside of
the breast where the simulated capsulorrhaphy marks
were made. The chest wall and corresponding capsule
are lightly scored with electrocautery. A long (at least 9-
inch) needle holder is used to place several interrupted
2-0 Ethibond sutures (polybutylate-coated polyester;
Ethicon, Somerville, NJ), each approximately 1.5 cm
apart. Sutures are placed though the capsule and muscular
tissue. This is done without the use of chest wall components in all cases except that of medial capsulorrhaphy,
for which it is necessary to incorporate periosteum
into the repair. A sizer is then placed, and the
result is evaluated with the patient in both the supine
and sitting positions. Modifications of the sutures can be
performed at this stage.
After satisfactory capsulorrhaphy repair with a sizer,
the capsulorrhaphy is reinforced with a running 2-0
Ethibond suture. The final implant is then placed.
Silicone implants were used in all patients. It is believed
by the authors that in performing revisionary surgery a
silicone gel–filled implant will produce less palpability
and wrinkling with better compressibility, yielding an
overall superior result. During approximately 20% of
inferolateral capsulorrhaphies, a significant bulge forms
in the upper-outer quadrant of the breast. This bulge
corresponds to the axillary tail of the breast and is treated
with a pilot incision 1 to 2 cm away from the capsulorrhaphy
repair at the center of the bulge, followed by
excision of a small amount of breast tissue (20-50 g).
Recurrent symmastia is treated with capsulorrhaphy and
an adjustable fill implant, which is filled over the course
of 3 to 4 weeks. A silicone implant is then used 3 to 4
months later.
The incision is closed in three layers and dressed with
gauze and Tegaderm (3M Health Care, St. Paul, MN). The
area of capsulorrhaphy is reinforced with foam tape. This
is left in place for 1 to 3 days. The patient is then wrapped
in a 6-inch Ace Bandage (BD Medical, Franklin Lakes, NJ)
overnight, and then placed in an underwire brassiere to be
worn day and night for the next 3 to 4 weeks. For patients
with symmastia, the Thongbra (Thongbra, Inc., Lyndell,
PA) is used. Light implant stretching exercises are started 2
weeks after surgery, with an emphasis on stretching
toward the area of capsulotomy.

 

Results
Seventy-five patients underwent a capsulorrhaphy procedure
preformed by the primary author between May
2002 and March 2006 (Figures 2 to 9). Four of these patients had primary augmentations performed by the
author, whereas the remaining 71 had primary augmentations
performed outside of his practice. The average
follow-up is 21 months, during which time there have
been no complications. Of the patients, 35 (47%)
required inferolateral capsulorrhaphy, 26 patients (35%)
required lateral capsulorrhaphy, 8 patients (11%) required
medial capsulorrhaphy, 3 patients (4%) required inferior
capsulorrhaphy, and 3 patients (4%) required
superolateral capsulorrhaphy (Figure 10). Of final
implants placed, 36% were smaller than those
removed, 37% were larger than those removed, and 27% were of equivalent size to the implants removed.
Most patients having inferolateral capsulorrhaphy had
smaller implants placed, whereas most patients having
capsulorrhaphy in other locations received larger
or equally sized implants. The difference between
mean preoperative implant size (381 cc) and mean
postoperative implant size (378 cc) is negligible. Of
lateral and inferolateral capsulorrhaphies, approximately
20% required excision of breast tissue. The
number of patients having a capsulorrhaphy associated
with a mastopexy was 37 (49%). Four patients
(5%) had unilateral capsulorrhaphy.
In May 2006 a questionnaire was distributed to all
subjects in the capsulorrhaphy study. Thirty-five patients
(47%) responded (Table) and were generally happy with
their results. On the basis of the comments on the questionnaire,
approximately one third of respondents reported
moderate to more severe pain after capsulorrhaphy.

 

Discussion
As the popularity of breast augmentation surgery continues,
so does the need to repair complications. Implant
malposition, symmastia, and the desire to change to
smaller implants are all indications that may benefit
from a capsulorrhaphy. It is important to evaluate the
patient before surgery in a supine position to assess the
displacement of the breast implant and symmetry.
Photography with the patient in the supine position is
important in demonstrating to the patient the extent of
any asymmetry, as well as the degree of any lateral displacement
of the breasts. The patient should be made
aware that the position of the areola will change with
respect to the capsulorrhaphy and that areolar repositioning
may be required.
As more experience has been gained with this technique,
it has become evident that there is no need to
excise capsular tissue and no need for percutaneous
suturing and that patients do not need to be placed in
cumbersome dressings or be taped for extended periods
of time. The mirror-image capsulotomy is an important
aspect of the repair, decreasing tension on the capsulorrhaphy.
The data indicate that inferolateral capsulorrhaphy
was used in most patients for whom a change to a
smaller implant was performed, reflecting the need for
reduction of pocket volume in superior and medial directions.
As always, surgical judgment is important in each
case, as is evaluation of the tissue and skin quality. A
patient with poor tissues who has already bottomed out will not do well with an inferior capsulorrhaphy and
placement of a large implant.
Capsulorrhaphy is a powerful technique in the plastic
surgeon’s armamentarium to deal with specific implant
problems. The technique as described allows a repositioning
of the breast implant in a straight-forward and predictable
manner. The results have held up over time,
while restoring symmetry and improving shape in patients
who have been disappointed with their previous results.

 

Conclusion
Breast capsulorrhaphy is a technique that can be used
for the repair of implant malposition and improving the
results in revisionary breast surgery. There is a high level
of satisfaction among patients. The patient should be
made aware that there may be significant postoperative
discomfort. All patients should be evaluated in both the
sitting and supine position before surgery and photographed
in the supine position from a “worm’s eye”
view. There is no need for excision of capsular tissue,
percutaneous suturing, or prolonged taping. The technique
is relatively straightforward and easy to learn, and
the results appear to last!