Safely Shaping the Breast after Implant Removal and Total “En Bloc” Capsulectomy Using the Mammary Imbrication Lift and Fixation Technique

Goals/Purpose: Implant-based breast augmentation is one of the most popular plastic surgery procedures performed worldwide. As the number of patients who have breast implants continues to rise, so does the number of those who request breast implant removal without replacement. Many of those individuals currently seeking breast implant removal are also requesting complete, or total intact “en bloc” capsulectomy for a variety of reasons. These patients often present a technical challenge in achieving a satisfactory breast shape. Breast implant removal, or explant surgery, often leaves the breast with a deflated area of central hollowing, significant subsequent breast and skin laxity, loss of projection, loss of conical shape, and proportional excess in the lateral breast. Breast implant explantation places the patient at significant risk for resultant breast skin excess with rippling and nipple inversion, as the pocket collapses down to the chest wall. Total capsulectomy with explantation likely increases the risk of these deformities, as more soft tissue is inevitably removed with the implant. Total capsulectomy of sub-muscular implants requires more dissection and may present a greater risk for pneumothorax, muscle edge bleeding and injury to deep vascular structures. Simultaneous mastopexy is often indicated in these patients in order to address the significant skin stretch and laxity excess frequently encountered after implant removal. There is little in the current scientific literature describing total intact capsulectomy technique and simultaneous mastopexy procedures. The few techniques that are described in contemporary publications all utilize wider undermining and/or sub-total or piecemeal capsulectomy techniques for sub-muscular breast implant removal. The following describes a reproducible, simple and safe series of steps that allows total and often intact capsulectomy through a large optical window, as well as, subsequent breast shaping with a mammary imbrication lift and fixation technique utilizing all absorbable suture material. Preoperative markings and intra operative adjustment maneuvers are detailed in order to help accommodate for dynamic breast implant pocket collapse. This technique focuses on preservation of dermis and blood supply aided with intraoperative sizers. Serial dermal imbrication is performed in order to decrease the risk of nipple inversion and post explant breast deformity. Interlocking PDS purse string suture is utilized for fixation of the areola upon inset. This is intended to help treat patients who have decided to “quit breast implants”. Here, we present our current method using the mammary imbrication lift and fixation technique after explant and total capsulectomy.

Methods/Technique: Between 2016 and late 2021, a total of 64 patients (mean age 42.95 years; range 27 – 78 years) underwent the described mammary imbrication lift and fixation technique with bilateral breast implant removal and total capsulectomy. Sub-muscular implants were present in 57 patients (89%) prior to surgery. Sub-glandular implants were noted in 7 patients (11%). A total of 128 breast implants were removed from 64 patients with all total capsulectomy and an attempted intact en bloc procedure prior to the mammary imbrication lift and fixation technique. The size of the breast implants removed ranged from 175 cc to 800 cc (average 360.66 cc). Volume could not be determined for 2 implants in the same patient placed over 30 years ago, due to rupture and loss of old medical records. The indications for surgery included the desire to not have breast implants anymore and smaller breasts in 18 patients (28.1 %), breast implant associated pain in 56 patients (87.5%), deformity and firm capsular contracture in 48 patients (75%), implant rupture in 11 patients (17.2 %), recurrent seroma in 8 patients (12.5%), implant malposition or rippling in 25 patients (39%), and symptoms or fear of acquiring breast implant illness in 47 patients (73.4 %). 10 patients (15.6%) had simultaneous fat grafting to the breasts performed during the same surgery. The complete intact capsulectomy and the mammary imbrication lift and fixation technique utilized is described further.

Results/Complications: Mean follow up was 6.5 months (range 1 to 36 months). Postoperative complications included minor cellulitis in one patient (1.6 %), late onset hematoma with infection in one patient (1.6 %), fat necrosis and pulmonary embolism in one patient with prior history of thromboembolic events (1.6%), and breast scar irregularity in 3 patients (4.6%) who required subsequent minor scar revision. 2 patients (1.6 %) underwent revision surgery with bilateral breast fat grafting to improve shape and add volume.

Conclusion: The mammary imbrication lift and fixation technique described here can safely and simultaneously be performed with a total intact capsulectomy and explant procedure. Unlike other procedures prior described, the mammary imbrication lift and fixation technique described here avoids wide undermining, intentionally opening the capsule, and subtotal capsulectomy. This technique allows total intact capsulectomy, preserves breast tissue and blood supply to the nipple, and confers a very small risk of postoperative complications. It can be considered for subsequent breast shaping in women electing to have their implants removed without replacement.