Daniel Fleming

Case 74: Ptosis and Augmentation

This patient with ptosis wanted breast augmentation. The suggestions included no large implants to lift breasts, not submuscular implants, mastopexy with relocation of nipple-areolar complex, having tuberous breasts perform mastopexy/augmentation in stages, and use of polyurethane-coated implants. Controversies included whether or not to use staged procedures and vertical mastopexy in preference to other types of mastopexy.

Case 70: Widely Spaced Breasts

This patient had tubular breasts and wanted them to be larger, D cup. Suggestion was high-profile implants through a periareolar incision but she would have no cleavage. The Group covered information on moderate profile implants and mastopexy with lifting the nipple-areolar complex higher, anatomical low height and extra projection with high-cohesive gel implants in front of the muscle, a variety of possible implants, and scoring of the bottom of the breasts.

Case 73: Double Bubble After Capsular Contracture Treatment

This patient had subglandular breast augmentation. Postoperatively, the implants did not seem to be positioned well and there was capsule contracture. She then had submuscular implants and developed double bubble with more fullness of the left medial breast. The discussion included the type and size of implant to use, the pocket position above or below the pectoralis, and recreation of the inframammary fold.

Case 97: Upper Pole Problem

This patient had breast augmentation with subglandular textured silicone gel implants through an inframammary incision. The upper poles appear blunted and palpably irregular but not hardened. Discussion centered around the size of implant, possible change in subglandular pocket, type of implant, and possible mastopexy.

Case 13: More Early Contracture

This patient had Baker grade 3 capsular contracture of the left breast 9 months after breast augmentation with a smooth gel implant submuscularly. The surgeon planned to replace the implant with a textured one in a subglandular pocket. The discussion included the question of using the pinch technique of the upper pole to determine the amount of fat in the tissues, the suggestion to place the implant superficial to the present pocket and not using the textured implant because this is associated with rippling.

Case 11: Synmastia

This patient desired to increase her breast size. Breast augmentation was performed with 450 mL round cohesive gel implants in the subpectoral. She developed breast deformity within 9 months. Further surgery was performed and the implants enlarged to 550 mL and placed in subglandular position. She developed synmastia postoperatively and wants to go larger. The Group’s advice included: do nothing further, use smaller implants and capsulectomy and close the pockets medially.

Case 49: Unexplained Possible Implant Rupture

This concerns a case of a patient who had breast augmentation, and 6 years later, a routine mammogram/ultrasound examination showed a very small amount of fluid, ‘presumably silicone’, to be present in each pocket. There was no history of trauma.

Case 98: Silicone Leak or Bleed?

This case is of a patient who had breast augmentation 10 years previously and now has hardening of the implants. On examination, there was Baker grade 1 on the right and Baker grade 3 on the left. MRI showed bilateral leak of gel while ultrasound did not show any leak. At surgery, the right breast showed no leakage and the implant was changed to a Silimed implant. On the left side, posterior capsulectomy was performed, and a small pocket of silicone gel was found outside the capsule. The contributors discussed the problem of gel bleed, its origin and its treatment. Also described were various types of implants and treatment of capsular contracture.

Case 71: Ruptured Implants

This case is about a patient who had breast augmentation 10 years previously using textured gel implants in the submuscular position. She presented with a lump in the axilla and ultrasound showed an extracapsular leak. Aspiration of the axillary mass disclosed silicone. The contributors discussed the removal of the implants with methods of removing the leaked silicone, whether capsulectomy or capsulotomy is advisable, and questions that should be asked of the patient.

Case 34: Late Revision

This 49-year-old patient had bilateral submuscular mammary augmentation with saline implants. Six months postoperatively, she had deflation of the right implant that was replaced. She now wants larger implants and better cleavage. There was discussion as to the type of implant for replacement, how to improve cleavage, whether to do capsulotomy, possible conversion to subglandular pocket, and how to handle mild double bubble. Ultimately capsulotomies with sharp dissection of the inframammary folds and larger implants were performed.