Breast augmentation is one of the most commonly performed cosmetic body procedures in the U.S.. While producing immediate and often dramatic changes in breast size and shape, it is a procedure that is associated with a variety of potential complications. Some of these complications are surgery-related (e.g., hematoma) while others are device-related. (e.g., capsular contracture) When all put together, the incidence of complications in breast augmentation surgery is likely underestimated. (at least by many patients)
While not all complications require revisional surgery for resolution, some do. One of these is breast implant malposition. With implants at two different horizontal levels, breast asymmetry results as the position of the nipple-areolar complex is different between the two breasts. Besides the change in breast implant size, the position of the nipple-areolar complex has been shown to be one of the most important factors in satisfaction with breast augmentation surgery. Thus, most plastic surgeons place great emphasis on optimal symmetry of implant position during surgery.
In the July 2014 issue of the Archives of Plastic Surgery journal, an article appeared entitled ‘Prevention of Implant Malposition in Inframammay Augmentation Mammaplasty’. In this study, 36 women underwent dual plane breast augmentation through an inframammary approach over a one year period. Seven of the 72 breasts developed implant malposition. The implant malpositions were divided into two types, a high (1) or lower nipple-areolar complex (6) compared to the mound position. The cause of these malpositions identified as either a short nipple-inframammary fold distance or failure to adequately fix and resecure the fascia back down to the rib cage.
While there are different incisional choices for breast augmentation surgery, the inframammary approach is the most commonly used. It allows for direct visualization of the pocket dissection, casues the least amount of adjacent tissue trauma and allows for direct comparison of the two implant positions. The inframmary approach is also the best to use when placing silcione implants for ease of insertion into the pocket. In my experience, this incisional approach provides the least risk of implant malposition. But implant malposition is not rare and the risk in my practice is in the 5% to 8% range.
The most common type of breast implant malposition, as this article illustrates, is when the implant remains too high and does not adequately settle into the desired position. This is due to inadequate release of the inner aspects of the pectoralis muscle closer to its sternal attachments. The root cause is usually insufficient appreciation of how much the original inframammary fold must be lowered. This is most manifest in small breasts with tight overlying skin. In those patients with more breast tissue, the amount the inframammary fold must be lowered is less or not at all.
The more infrequent type of breast implant malposition is when the implant ends up too low, thus causing a high nipple-areolar complex to occur. This is due to release of the inframammary fold and an ineffective repair of it after implant placement. This is an issue of particular relevance in large implants with thin breast tissues, making them prone to bottoming out from lack of tissue support. With even slight overdissection of the bottom portion of the pocket, this type of breast is prone to this implant malposition problem.
The pocket dissection in placing breast implants is the most critical aspect of the procedure that leads to implant symmetry or asymmetry. Because correcting a low positioned implant is more challenging and unstable than lowering a high one, there is a strong tendency in surgery to be conservative about how low to make the breast implant pocket. This accounts for the more frequent higher breast implant malposition problem.
Dr. Barry Eppley
Indianapolis, Indiana