Strattice for Recurrent Capsular Contracture?

Capsular contracture and recurrent capsular contracture is a challenging problem for both the patient and surgeon. Acellular dermal substitutes have been used for rippling, implant and inframammary fold malposition. It may be that an additional benefit of acellular dermal matrices is to reduce the recurrence of capsular contracture.

I have found in certain cases of recurrent capsular contracture for Strattice to have been helpful as an interface between the access incision and the breast implant. It maybe that this interface serves as a mechanism to prevent capsular contracture.

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Mastopexy Augmentation

More frequently, I am seeing patients in my office who have had large implants for quite some time and now want their implants exchanged for smaller implants and would also like their breasts lifted. These operations are typically challenging.

As one reduces the size of the breast or changes the shape of the breast, it is important to respect the blood supply of the nipple areola complex. For example, this patient had a prior mastopexy augmentation via a superior crescent incision in the submuscular position. Therefore, one needs to be cognizant of the remaining blood supply when attempting to raise the nipple areola complex.

This patient underwent bilateral capsulectomy, bilateral removal of saline implants for Mentor smooth round high profile silicone gel implants, and mastopexy via an oblique pattern. I have found that the vertical, oblique, pattern provide excellent projection while removing excess skin. I have found that many women appreciate the breast projection that these patterns in combination with the high profile implant provide.

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Breast Augmentation. Bra Sizing.

The breast augmentation consultation can often bring anxiety to the patient as there are many questions to be addressed or discussed. These variables can range from topics pertaining to the patient (medical conditions, height & weight, bra size, pre-operative breast shape); surgeon (preference for above vs. below the muscle, incision choice); or implant (saline vs. silicone, smooth vs. textured, profile).

Determining bra size in breast augmentation consultations creates a common frame of reference for the physician and patient to discuss post operative bra size. The first step in the physical examination is observation. In the observation step, both the patient and I stand in front of the mirror and with the same perspective identify any asymmetries between the breasts.

Breasts are more often than not asymmetric with either a discrepancy in breast volume, breast fold position, nipple position, shoulder height, and chest wall asymmetry. After this step of the physical examination we proceed to pre-operative bra sizing.

Bra Sizing: The BasicsThe size of a bra is determined by two factors: 1) The Band Size & 2) The Cup Size.

The Band Size

Step 1. The band size of the bra is relatively a fixed number determined by the circumference of a woman’s chest. This number can be measured with a measuring tape in inches, just beneath the breasts, in the crease where the band of the bra would be placed.
Step 2. Add five to the number of inches determined from this measurement. For example, if the measured number is 27” then if you add the number 5, the result is 32. Therefore the band size of the bra necessary is 32. If the measured number were 28” adding 5 would result in a 33 band. One quickly realizes when bra shopping that there are no odd number band sizes, so one would try on a 32 or 34 band bra to see which fit best. In this scenario, the 32 bra would be worn on the last of three clasps and a 34 bra would be worn on the first of three clasps.The band size is relatively consistent in women of adult age as the bony ribcage has completed growing. This number will change to a small degree if a woman gains or looses weight around the chest where the band of the bra would normally be placed. The so called “bra fat”.2)

The Cup Size

I have found the “Size Me Up” system designed by Edward Pechter in Valencia, CA to be the best system for determining cup size. In the “Size Me Up” system, the dome of the breast is measured by starting the measurement from where the breast begins on the side of the chest, passing over the nipple and finishing towards the sternum where the breast ends. The resulting measurement is then compared on the “Size Me Up” chart to determine the cup and bra size.One point I have learned is that the “cup volume” or “measured breast dome” increases depending upon the band width. That is, a “C” cup represents a smaller volume breastfor a woman with a small ribcage (i.e.32 band size bra, C-cup) than a woman with a larger ribcage (i.e. 36 band size bra, C-cup).

In my experience, the best manner in which to predict the post-operative cup size is to determine the pre-operative bra size measurements and base diameter of the patient. The post-operative cup size can be predicted by using these measurements with the volume per base diameter of the breast implant.While the prediction of post-operative cup size is not exact, I find this step to be helpful, as it facilitates a common frame of reference between the patient and surgeon.

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Capsular Contracture Surgery

Correction of capsular contracture and revision breast surgery are challenging cases. This patient had painful capsular contracture and left breast double-bubble deformity. Correction of this asymmetry was done with bilateral "en bloc" capsulectomy, re-set of the inframammary fold, and change of implant profile.

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Breast Augmentation. Incision Selection

During the initial consultation for breast augmentation patients often ask questions regarding which approach is best to place the breast implant. There are advantages to each incisional approach. Which incision the patient decides upon depends upon their preference as well as surgeon input regarding pre-existing anatomical limitations.

Typically for silicone breast augmentation one of three incision choices is selected. The three possibilities are:

1. Peri-areolar
2. Inframammary
3. Transaxillary

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Breast Augmentation. Recovery from Surgery

The typical breast augmentation patient in our practice is an athletic professional woman who wants to return to work or exercise soon after surgery. Frequently patients have questions in consultation regarding recovery following breast augmentation.

I have found that our patients recover very quickly and with minimal pain and discomfort. Often I find that I have to slow my patients down.
Below I have included the post-operative medication and exercise schedule.
1. Emend 40 mg by mouth mourning of surgery to prevent nausea.2. Percocet 5/325 by mouth every 4-6 hours as needed for pain.
3. Valium 5 mg by mouth every 8 hours as needed for spasms or sleep.
4. Keflex 500 mg by mouth four times per day. (Antibiotic)
Post-Operative Exercise Regimen:
1. First week post-operatively. Walking and Exercise Bicycle.
2. Second week post-operatively. Exercise Bicycle. O.K. to add machine Leg Exercises.3. Third week post-operatively. O.K. to add Arm Exercises.4. Fourth week post-operatively. O.K. to add Chest Exercises.
5. After six weeks patients have unrestricted return to exercise such as Pilates, Yoga, Contac Sports, etc.

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Breast Augmentation. Breast Implant Proportion

Women often present to the office in consultation mentioning that they want to maintain a natural breast augmentation look. Patients will say, "I want to look better in my bikini or in my strapless dress and I don't want anyone to know I have had a breast augmentation."

One of the more challenging aspects of breast augmentation surgery is to make sure that the surgeon and the patient are on the same page with regard to breast volume goals. Typically, we have patients bring in photographs of breast sizes and shapes that they like so that we can first determine if the patient's goals can be easily obtained.

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Breast Augmentation. Implant Size Selection.

Implant selection can often seem daunting to the patient who is about to undergo breast augmentation. Not only do patients find it difficult to discern among different implant profiles, but also implant volumes.

Breast implant volume is described in cubic centimeters or cc's. A cubic centimeter corresponds to the volume of a cube measuring 1 cm × 1 cm × 1 cm. One cubic centimeter corresponds to a volume of 1⁄1000 of a liter, or one milliliter. Therefore, 1 cm3 ≡ 1 mL. Often patients find this nomenclature to be confusing. It is easier to relate to this volume with a frame of reference.

A standard can of soda in the United States, Diet Coke, for example is 12 fluid oz. or 355 ml. A common breast implant volume is also on is order of magnitude. Often patients have difficulty decided between two implant sizes that differ by 25 cc. I tell the patients that a standard beverage "shotglass" is 30 cc. Once patients understand the relatively small difference in volume, that the decisions become much easier.

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