G. Patrick Maxwell

Use of the Acellular Dermal Matrix in Revisionary Aesthetic Breast Surgery

BACKGROUNDnRevisionary augmentation and revision of augmentation mastopexy are of considerable interest to plastic surgeons who perform breast surgery because of the procedures complexity. In these cases, surgeons are faced with either thinned breast tissues resulting from large breast implants with tissue stretch or encapsulation caused by excessive scarring. To our knowledge, there are currently no large-series studies describing the use of acellular dermal matrices (ADM) in cosmetic breast surgery.nnnOBJECTIVEnThe authors describe the use of the ADM in revisionary breast surgery to establish the aesthetic breast form.nnnMETHODSnA retrospective chart review was conducted of 78 consecutive patients who underwent revisionary breast augmentation and augmentation mastopexies with ADM during a period of just over two years (October 2005 to January 2008). Data collected included patient characteristics, complications, outcomes, and reoperation rates.nnnRESULTSnSeventy-eight procedures were performed with ADM during the two-year period, with a minimum of 12 months of follow-up. There were two complications requiring reoperations for a hematoma and implant malposition, respectively. There were no Baker III or IV capsular contractures at one year postprocedure.nnnCONCLUSIONSnRevisionary augmentation and revision of augmentation mastopexy are commonly performed procedures and they have a significantly higher complication rate than primary procedures. This series shows that the ADM can be used both safely and effectively in revisionary cases, resulting in decreased rates of capsular contracture and implant cushioning/stabilization.

The evolution of breast implants.

Breast augmentation remains one of the most common procedures performed in the United States. However, shape, feel, safety, and longevity of the implants remain important areas of research. The data provided by manufacturers show the safety and efficacy of these medical devices. Clinicians should strive to provide ongoing data and sound science to continue to improve clinical outcomes in the future. This article explores the evolution of breast implants with special emphasis on the advancement of silicone implants.

The Neopectoral Pocket in Revisionary Breast Surgery

Increasing numbers of patients are presenting with volume-depleted breasts as a result of large saline implants that were placed under the pectoral muscle. To treat this problem, the authors introduce a revisionary surgery technique, called the neopectoral pocket, designed for patients with subpectoral implants. This technique is useful for the management of late breast augmentation complications, such as capsular contracture and implant malposition, including double bubble breast deformity, Snoopy breast, and symmastia. The creation of the neopectoral pocket maintains muscle coverage over the implant, allowing control of pocket size while minimizing trauma.

Revisionary Breast Surgery With Acellular Dermal Matrices

Revisionary breast surgeries are challenging, and advanced techniques must often be utilized in the correction of the underlying anatomical deformities. In this Featured Operative Technique, the authors describe their method, which includes a combination of revisionary surgery techniques with site change and acellular dermal matrices. This use of acellular dermal matrices has four indications based on the underlying clinical presentation: (1) as a lower pole implant interface (usually for revision mastopexy), (2) as a capsular contracture treatment (technically similar to lower pole interface), (3) as a tissue thickener (superomedial or inferolateral implant interface), or (4) as an implant stabilizer (malposition correction).

Efficacy of Acellular Dermal Matrices in Revisionary Aesthetic Breast Surgery: A 6-Year Experience

BACKGROUNDnAugmentation mammaplasty and augmentation mastopexy are associated with a substantial primary and secondary revision rate. Capsular contracture (CC), implant malposition, ptosis, asymmetry, and rippling are the main reasons for revisionary surgery in these patients. Traditional corrective techniques have not been completely reliable in preventing or treating these complications. Recently, acellular dermal matrices (ADM) have been used to assist with revisionary surgery with promising results.nnnOBJECTIVEnThe authors review their 6-year experience using ADM for revisionary surgery in aesthetic patients and evaluate long-term outcomes with this approach.nnnMETHODSnPatients who underwent revisionary breast augmentation or augmentation mastopexy with ADM in conjunction with standard techniques over a 6-year period between October 2005 and December 2011 were retrospectively reviewed. Only patients with at least 1 year of follow-up were included in the analysis.nnnRESULTSnA total of 197 revisions were performed (197 patients). Reasons for revision included CC (61.8%), implant malposition (31.2%), rippling (4.8%), ptosis (4.8%), implant exposure (1.6%), and breast wound (0.5%). The mean ± SD follow-up period was 3.1 ± 1.1 years (range, 0.1-6.1 years). The complication rate was 4.8%, including Baker grade III/IV CC (1.6%), infection (1.6%), implant malposition (0.5%), hematoma (0.5%), and seroma (0.5%). Most (98%) revisions were successful, with no recurrence of the presenting complaint.nnnCONCLUSIONSnThe use of ADM in conjunction with standard techniques for the reinforcement of weak tissue in revision augmentation and augmentation mastopexy patients appears to be effective.

Non-cross-linked porcine acellular dermal matrix in revision breast surgery: long-term outcomes and safety with neopectoral pockets.

BACKGROUNDnRevision breast surgery represents a significant problem among patients who have undergone augmentation mammaplasty. Current techniques do not adequately prevent recurrence, thus requiring novel approaches, including placement of Strattice (LifeCell, Branchburg, New Jersey), a non-cross-linked porcine acellular dermal matrix, to minimize recurrence.nnnOBJECTIVEnThe authors review their experience and long-term outcomes with placement of Strattice in revision breast surgery patients who underwent previous augmentation mammaplasty.nnnMETHODSnAll patients in the authors practice with a previous history of augmentation mammaplasty who underwent revision breast surgery with placement of Strattice between January 2007 and December 2011, and who had a minimum of 12 months of follow-up, were included in this retrospective study. A total of 106 patients met the studys inclusion criteria.nnnRESULTSnAverage patient age was 42.3 years and average follow-up time was 3.1 years. Indications for revision surgery included capsular contracture (51.9%), implant malposition (38.7%), and ptosis (8.5%); approximately 40% had ≥1 previous attempts to correct the presenting complaint. Revision surgery included creation of neosubpectoral pockets with retention of previous noncalcified capsules in 81% of patients with subpectoral implants. Presenting complaints were successfully resolved in all patients. The overall complication rate was 0.9%.nnnCONCLUSIONSnAdding Strattice to traditional revision surgery procedures results in reliable, durable repair of the presenting complaint with minimal associated complications. Treatment with Strattice in conjunction with noncalcified capsules retained during site change also appears to be safe. The data support a role for Strattice in revision breast surgery for patients who have undergone previous augmentation mammaplasty.

Possible Future Development of Implants and Breast Augmentation

Since the introduction of the silicone gel prosthesis in 1962, breast augmentation has become one of the most frequently performed operations in plastic surgery. As we strive for perfect results, it is important to continue to gather and review data evaluating innovative techniques and devices. Now we even have more options available for breast augmentation, whether we use them in combination or alone. By combining all of the available options (acellular dermal matrix products, silicone implant, fat grafting), we have been able to create bioengineered breasts with high patient and surgeon satisfaction. As always in plastic surgery, our concern is with safety; as newer technology and products are introduced to us, patient education, consent, and follow-up remain important.

Acellular Dermal Matrix in Aesthetic Revisionary Breast Surgery

Breast augmentation is one of the most commonly-performed cosmetic procedures worldwide. Unfortunately, many women require revisionary surgery related to unsatisfactory results or complications such as capsular contracture, implant malposition, and ptosis. While, historically, surgeons have relied on often-imperfect native tissue to correct these deformities, acellular dermal matrix (ADM) offers a new option for solving these difficult aesthetic problems. In this article, the authors provide background information about the role of ADM in providing excellent and lasting results to cosmetic breast augmentation patients, and they describe their method of subpectoral revisionary augmentation with ADM.

The Efficacy of Botulinum Toxin A in Post-Mastectomy Breast Reconstruction: A Pilot Study

BACKGROUNDnBotulinum toxin A has been successfully used in a variety of areas to temporarily obliterate muscle mobility for either functional or aesthetic gain. Tissue expander-based breast reconstruction has been plagued with pain and discomfort.nnnOBJECTIVEnThe purpose of this pilot study was to evaluate the role of a neurotoxin (Botulinum toxin A) in expander-based breast reconstruction.nnnMETHODSnThirty patients underwent mastectomies with immediate expander or acellular dermal matrix reconstruction. The neurotoxin group (n = 15) received 40 units of neurotoxin (Botulinum toxin A, Allergan, Inc, Irvine, CA) into each pectoralis major muscle through 4 serial injections and the placebo group (n = 15) received 4 serial injections of 0.9% NaCl. All patients were followed over 1 year, and patient demographics, VAS (visual analog score), laterality, office visits, amount of expansion and number of times to full expansion, and amount of narcotics required were recorded. Statistical significance was considered as p < .05.nnnRESULTSnThere were no significant differences between the two groups in terms of age, laterality, expander size, or complications (p = .46-.66). There was a significant difference between the two groups in the VAS score, demonstrating decreased pain in the neurotoxin group (p < .05). In addition, there was a significant increase in the volume of expansion per visit in the neurotoxin group as compared to the placebo group (p < .05). There was no significant difference in narcotic use in the first 3 days after surgery; however, there was a significant decrease in use of narcotics from 7 to 45 days in the neurotoxin group (p < .05). There were no complications associated with the use of the neurotoxin.nnnCONCLUSIONSnThe infiltration of the pectoralis major muscle with neurotoxin in immediate, expander-based reconstruction may be beneficial in reducing pain and expediting expansions.

Prepectoral Revision Breast Reconstruction for Treatment of Implant-Associated Animation Deformity: A Review of 102 Reconstructions

BackgroundnAnimation deformity is a direct consequence of subpectoral implant placement for breast reconstruction following mastectomy. Current treatment options ameliorate but do not address the source of the problem. Moving the implant from subpectoral to prepectoral has the potential to eliminate animation deformity.nnnObjectivesnDescribe the technique and outcomes of prepectoral revision reconstruction in over 100 cases and discuss patient selection criteria for a successful outcome.nnnMethodsnPatients who presented with animation deformity following two-stage implant reconstruction were included in this retrospective study. Revision surgery involved removal of the existing implant via the previous incision site along the inframammary fold, suturing of the pectoralis major muscle back to the chest wall, creation of a prepectoral pocket for the new implant, use of acellular dermal matrix to reinforce the prepectoral pocket and completely cover the implant, and fat grafting to enhance soft tissue. Patients were evaluated for resolution of animation deformity and occurrence of complications during follow up.nnnResultsnFifty-seven patients (102 breasts) underwent prepectoral revision reconstruction with complete resolution of animation deformity. Complications occurred in 4 breasts (3.9%) and included seroma (2 breasts), skin necrosis (3 breasts), and wound dehiscence (1 breast). All 4 breasts with complications had their implants removed and replaced. There were no incidences of infection or clinically significant capsular contracture in this series.nnnConclusionsnRevision reconstruction with prepectoral implant placement and complete coverage with acellular dermal matrix resolves animation deformity and results in aesthetically pleasing soft breasts. Patient selection is critical for the success of this technique.nnnLevel of Evidence 4