Posted by Dr. Hardesty

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Depending on the decision of the patient and the plastic surgeon, a malposition of breast implants in one patient could be considered a desired result in another patient. Other items we will discuss include “double bubble,” synmastia and other common topics. The goal of this post is to define the most common breast implant malposition situations and treatment options.

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Breast Implant Placement

If the breast implants can be placed high on the chest wall, the result is breasts with a significant upper pole fullness. If the breast implants are placed centrally, balanced upper and lower breast poles are accomplished. Lastly, if the implants are placed low, a lower pole fullness is achieved with a “tear drop” appearance.

Malposition

Causes of Breast Implant Malposition / Lateral displacement

If the breast pocket is too large, the implants can migrate into the axillae (armpit), which is quite noticeable when lying down and sometimes causes breast pain.

Inferior displacement

If the implants are placed too low, the appearance of the breast is called pseudoptosis, resulting in the majority of the implant being lower than the nipple areolar complex (NAC) — and the NAC rotates upward. This can result in the unwanted result of the NAC rotating out of the bra or bathing suit.

Another presentation of an implant placed lower than the inframammary fold is referred to as a “double bubble.” This is caused by the indention from the original inframammary crease or fold on the breast implant, resulting in a bulge (or bubble) above and below the original inframammary crease/fold. The consequence is often autorotation of the NAC rotating upward and thus being located higher than desired and the majority of the volume of the breast lower than desired.

Superior displacement

Most often seen with capsular contracture, or a lack of the breast implant “dropping” into place; the appearance is a prominent, overly projecting upper pole.

Medial displacement

When the breast implant is medially displaced, often the cleavage point is elevated, giving an odd appearance referred to as an “unibreast,” “bread loaf” deformity or technically as synmastia.

Treatment

For all of the above described, early malpositioned breast implants (within the first six weeks after breast enhancement surgery) can be successfully treated using nonsurgical external splinting in the following ways:

If inframammary fold (IMF) is too low take a shoe string and tie it so shoe string can support around your the IMF (breast crease)

After creating the correct loop size place shoe string neck and under the IMF.

A. Lateral displacement

• Taping
• A wire bra

B. Inferior displacement

• A shoe string around the neck and under the breast mound
• Taping
• A wire bra

C. Medial displacement

• A “T” bra — a device that places pressure centrally over the breast bone (maniburium)
• Gauze rolled up and placed in the cleavage area and breast wrapped with an elastic (“ace” type) elastic compression bandage

D. Superior displacement

• Unilateral — a breast band that is placed like a sash
• Bilateral
• A breast band over both breasts
• Intermittent manual pressure by hands
• “Table top” pressure on the superior breast mound while the patient bends at the waist at the edge of a table

Late Malposition

For all of the above described, late malpositioned breast implants (more than six weeks after breast enhancement surgery) can usually only be treated using the surgical techniques including acellular dermal matrix (ADM).

Lateral malposition

• Capsulloraphy (suturing the breast capsule together)
  +/- with the use of the ADM technique to reinforce the suture line

Inferior malposition

• Capsulloraphy — to reinforce the suture line making the breast capsule, allowing the implant to sit higher in the new the breast pocket

+/- with the use of the ADM technique to reinforce the suture line

Medial malposition

• Also known as synmastia, this is probably the most difficult of all of the malposition situations to treat
• Capsulloraphy can be used

+/- with the use of the ADM technique to reinforce the suture line

Superior displacement

• Capsulotomy is making precise incisions in the breast capsule, allowing the implant to sit lower in the new breast pocket
• Capsulectomy (excising the breast capsule) also allows the implant to sit lower in the breast pocket
• Secondary to capsular contracture treatment, placement of an interposition ADM graft — placed to provide lining where the capsule was resected

Conclusion

Breast implant malposition after breast augmentation, while unusual can be corrected using surgical techniques of capsulorraphy, capsulectomy and the use of the acellular dermal matrix (ADM) when needed.