Paul E. Chasan, M.D., F.A.C.S. La Jolla, CA Scripps Memorial Hospital U.C.S.D. Medical Center
Implant malposition without capsular contracture is a common problem that has received little attention. Malposition of the implant in the inferior, lateral and medial directions can be corrected predictably and relatively simply with capsulorrhaphy and mirror image selective capsulotomy. Additionally, capsulorrhaphy can be used to create a smaller pocket to preserve anterior projection and prevent lateral and inferior displacement when changing to a smaller implant.
11 patients underwent capsulorrhaphy for either implant malposition or implant size reduction. Improved appearance and symmetry of the breast was accomplished in all patients without increased complications.
Since the introduction of breast capsulorrhaphy or internal bra in 1986 by Drs. Spear and Little and its publication in 19881, only one reference to this topic has been made2. With nearly 3 million breast augmentation procedures performed to date in this country, breast implant malposition without capsular contracture is a clinical entity that is underdiagnosed and undertreated. There is also a significant population of patients that desire a change to a smaller implant size. By placing a smaller implant into an existing larger pocket, projection is diminished, medial fullness is diminished, and lateral displacement occurs on recumbence. Capsulorrhaphy as described below is a predictable and effective method to recontour the shape and size of the implant pocket resulting in better shape and appearance of the breast.
The patient is marked in the sitting position. Simulation of the capsulorrhaphy is performed digitally, and then marked. The patient is then placed in a supine position and the process is repeated. The lines are then connected in a single curvilinear line. The implant is manipulated away from the proposed line of capsulorrhaphy to check the tightness or turgor of the capsule. In most cases, a decision to perform a mirror image selective capsulotomy is made. This is especially beneficial when performing a lateral or inferior capsulorrhaphy.
I prefer general anesthesia. The breast implant is approached through existing incisions. Once the implant is removed, the anterior capsule is tattooed percutaneously with a needle and methylene blue at the previously marked external line. A line is drawn along the margin of the capsule. If a capsulotomy is to be performed, it is done prior to performing the capsulorrhaphy. A 2-0 Ethibond running suture is used as a single layer to plicate the anterior capsule to the posterior capsule equidistant from the capsular margin. The suture is begun well outside the previous tattooing and gradually wider bites are taken until the area of tattooing is reached, then gradually smaller bites are taken at the end to ensure a smooth transition. A sizer is placed and the result is evaluated. Slight irregularities are treated with single interrupted sutures and under corrections are treated with an additional row of suture. There is no need to take purchase of the deeper intercostal tissues as this adds nothing to the strength and adds only to post-operative pain. The only exception is when performing a medial capsulorrhaphy, it is important to take a bite of the parasternal periosteum. With each suture manipulation it is important to evaluate the patient with a sizer in place in both sitting and supine positions.
A final inspection is performed with sizer in place, then with the implant in place. The wound is closed in three layers, and then dressed with gauze and Tegaderm. The area of capsulorrhaphy is then taped with 1” and 2” foam tape reinforced with Transpore tape. This is left in place for one week. The patient is initially wrapped in a 6” ace overnight, then placed in an underwire bra to be worn day and night for 3-4 weeks. Light implant stretching exercises are started two weeks post-operatively with emphasis towards the area of capsulotomy.
This technique was used on 11 patients between 3/1998 and 12/2002 with an average follow-up of 10 months. The results have been consistently good (figs. 1 to 6). No complications were identified.
As more breast augmentations are performed, there will continue to be a need for reoperative breast surgery. Capsulorrhaphy is a powerful tool that has received very little attention; in fact, there has been only one reference in the literature since 1988. Adhering to the following principles ensure a predictable result. Performing a mirror image selective capsulotomy takes the tension off of the line of plication of the capsulorrhaphy. Tape reinforcement for one week following the capsulotomy not only helps take the tension off the repair, but also obliterates the dead space. Lastly, being very precise in the placement of the sutures, being very patient with the placement of the sutures, and being objective in the evaluation of the placement of sutures. This technique requires multiple sizer placements and table sitting adjustments “to get it right”, but the reward of a beautiful result is worth it.
Breast capsulorrhaphy is a powerful technique that is safe and reliable for the repair of breast implant malposition and improving the results in reoperative breast surgery. It is a technique that has had little attention in publications and, thus, is probably underutilized.
- Spear, S.L., Little,J.W. Breast Capsulorrhaphy. Plast. Recostr. Surg. 81(2):274, 1988.
- Eaves, F.F., et. al., Endoscopic techniques in aesthetic breast surgery. Clin.Plast. Surg. 22(4):683, 1995.
- Rahban, S.R., Wilde, M.K., Chasan, P., Skin sparing mastectomy with sun flap closure. Ann. Plast. Surg. 43:452, 1999.