Mesh repair for breast implant bottoming out
Among the common complications of breast augmentation, breast implant displacement is frequently overlooked. Patients often read about capsular contracture, deflation, and rippling but, fail to recognize bottoming out or lateral displacement even in its most severe form.
When more than half of a breast implant is below the nipple, the implant is said to have “bottomed out”. Lateral displacement is recognized when the patient lays back and the implant falls into their armpit producing abnormally wide cleavage. Both of these problems can be fixed and either can occur immediately after surgery or years later depending on the cause.
There are really two causes of implant displacement. Surgical technique and weak soft tissue support.
When surgical technique is the cause the surgeon over-dissects the implant pocket either into the patient’s armpit or below the intended level of the breast crease. This large pocket allows the implant to move either too far laterally or too far inferiorly resulting in either lateral displacement or bottoming out. If technical error is the cause, the patient would notice displacement soon after surgery.
Weak soft tissues can result in bottoming out or lateral displacement months or years after surgery. In this scenario, the weight of an implant overwhelms the weakened soft tissues resulting in bottoming out or lateral displacement. Often this is exacerbated long-term by contraction of the pectoralis muscle in those patients who have their implants under the chest wall muscle. As the muscle contracts it pushes the implant into the area of greatest soft tissue weakness. The “vector” of these forces is down and out - the exact areas affected by bottoming out and lateral displacement. Patients who have weak soft tissue support as the result of chronic smoking, large implant size, extreme changes in breast volume (for example, a normally B cup breast who goes to a DD while nursing), or massive weight loss are especially at risk for implant displacement.
Diagnosis of bottoming out or lateral displacement is more subjective than it is objective. In part, this is one of the reasons for the delay in diagnosis and treatment. Patients who are unaccustomed to larger breast size often don’t know how far their new breasts should fall into their armpits when they lay back and only see their surgeons when the problem becomes extreme. The same is true of bottoming out.
Often patients will recognize bottoming out when they can’t comfortably wear demibras without concern that their nipples will be exposed. The same can be true of bathing suit tops which seem to fit well along the bottom of the breast but, threaten to reveal the areola or nipple at the top. Sometimes women complain that their bras just don’t fit well or that their nipples look “too high”.
When patients have their incision under their breast, they often notice that their incision has crept from the crease onto the skin of the lower breast. The incision hasn’t moved in these cases, rather, the implant has descended moving the crease to a new, lower position.
Sometimes patients notice more rippling along their cleavage and along the bottom of the breast as the implant sinks below the pectoralis muscle. This is especially true of saline implants which tend to ripple more than their silicone gel counterparts.
Lateral displacement is as often noticed as unnaturally wide cleavage when lying flat as it is a feeling of the implant wanting to slide into the armpit. Often patients report that the problem has worsened over time since their surgery.
How frequent is bottoming out? There is no way to know. Surgeons are typically reluctant to mention it when the patient doesn’t bring it up. Some surgeons are concerned that the patient will blame them for the problem even if they had little to do with it. Some surgeons have had such poor experience with bottoming out repair and recurrence that they only offer surgery to the most severe cases.
Patients frequently ask if mild bottoming out or lateral displacement will get worse over time. The answer is likely, yes. The forces that cause these problems tend to compound over time and we all know that our skin and soft tissues weaken as we age. The effects of chronic sun exposure and smoking weaken the support systems of the breast just as they lead to jowling and wrinkles in the face.
Patients also frequently ask about nonsurgical treatment options. While wearing a good supportive bra around the clock may slow the progression of bottoming out and lateral displacement, the forces that cause these problems remain. Many patients grow frustrated with support bras and eventually decide that a surgical repair is in their best interest.
The decision as to when to repair bottoming out and lateral displacement is complex. Obviously, no patient wants to have a revision. Factors such as financial cost, time off work, pain and the fear and anxiety that accompany any surgical procedure need to be considered. Patients also need to consider the time of the year, remembering that these problems may be harder to conceal in a bathing suit than they might be in a winter jacket.
TRADITIONAL SURGICAL REPAIR
The traditional repair for both bottoming out and lateral displacement has been the same. The procedure, technically called a capsulorrhaphy, involves closing off the unwanted area of the implant pocket with permanent sutures placed in the operating room. In order to do a capsulorrhaphy the implant is temporarily removed in the operating room to avoid any damage. Once the repair is complete the implant is replaced.
Sometimes patients change implants at the time of the repair. When patients experience rippling along with bottoming out, many surgeons will suggest a change from a saline to a silicone gel implant at the time the repair is performed. It is well known that silicone implants ripple less than saline implants and patients may qualify for silicone implants at the time of their revision while they might not have at the time of their initial surgery.
Patients should be vigilant that some surgeons suggest switching to a larger implant to “treat” bottoming out. Larger implants are also typically wider implants so moving to a bigger implant will increase the proportion of the implant which is above the level of the nipple making the bottoming out less conspicuous. Unfortunately, larger implants are always heavier implants and as a result, the stress on the already weakened soft tissue is even greater.
Getting into a vicious cycle of more bottoming out and bigger and bigger implants is guaranteed to result in a dissatisfied patient.
A capsulorrhaphy is usually performed through the patients original breast augmentation incision unless the original incision was in the axilla or umbilicus. In these instances, a new incision either around the areola or under the breast will likely be needed. The surgery is typically done as an outpatient under either sedation or general anesthesia. Pain is often less after a capsulorrhaphy than it was after the initial procedure and, in fact, patients need to be reminded NOT to be overly active after a revision no matter how good they feel. Surgeons will have their own protocols following a revision but all will reiterate the importance of minimizing bouncing and the importance of wearing good breast support.
MESH FOR BREAST
Capsulorrhaphy is a flawed procedure in most patients. Without too detailed an explanation, most patients understand the inherent problem with sewing together tissues which have shown themselves to be weak and expecting them to support the stress that caused them to fail in the first place.
Statistics of capsulorrhaphy failure rates are hard to come by. Few surgeons take measurements of nipple to fold distance and most are disinclined to admit that a repair has failed. Some have placed the failure rate as high as 50%.
I became interested in bottoming out after a patient who came to see me failed a capsulorrhaphy. Despite what I thought was a perfect repair, the patient had recurrent bottoming out within 2 months. She was frustrated and so was I.
I had to rethink my concept of bottoming out and, in doing so, drew from my training in general surgery. In general surgery, hernia repair is quite common. In the case of a hernia, the weakened tissues fail, resulting in bulging of intra-abdominal contents through the hernia defect. For twenty years, general surgeons have realized that simply sewing these weak tissues together was guaranteed to fail. The body is simply too strong for the short term repair provided by sutures. The solution in hernia repair has been the introduction of something permanent and stronger than the bodies weakened tissues.
This material called mesh is very similar to the screen on your windows. Like window screen it has small holes which act as a scaffold for scar tissue to grow into. The mesh is made of the same material that permanent stitches are made from. The mesh becomes “incorporated” within a couple weeks following surgery as scar tissue surrounds it. In essence it becomes part of the scar and part of your body.
My idea was to use this mesh and to anchor it to the strongest material possible, the tight sheath of periosteum that surrounds the bones of the body. This rib periosteum is very strong and can easily support the weight of a breast implant, regardless of size, without failing. While initially I used a flat piece of mesh, it became clear that a sling or hammock of mesh would more exactly accommodate an implant. This design and method of placement has been described in a issued U.S. patent.
Like the capsulorrhaphy, patients who undergo mesh repair are initially limited in their activities. Patients should wear a supportive bra, typically a jog bra, and limit any activity which might involve bouncing such as running, aerobics or horseback riding. The periosteum of the rib to which the mesh is attached is very vascular and initially could bleed if a patient were too active. Sometimes, if a significant amount of capsule work is needed, a small drain may be placed for a day or two. This drain limits any bleeding around the implant and mesh and is removed in the office.
Also like capsulorrhaphy, patient may elect to replace their saline implants with silicone gel implants. While the rippling which concerned them will be greatly diminished after the repair, patients may enjoy the improved softness that silicone gel implants convey over their saline counterparts.
Thus far, the results in dozens of patients have been encouraging. Patients who have undergone mesh repair have had little pain and there have been no incidence of infection, mesh exposure or extrusion, or mesh induced injury to the implant. Mesh palpability – the ability to feel the mesh through the skin – has been minimal and similar to the feel of the implant itself through the skin. Two patients have had bleeding complications and both have attributed their bleeding to overexertion in the first several weeks after surgery. In both cases, the mesh was easily opened, blood evacuated and the implant replaced without difficulty. One patient has experienced “slipping” of the anterior leaf of mesh and will need additional sutures to secure this mesh portion. One patient had pain over the edge of the mesh and a small piece of the repair was removed. Other than these few patients there have been no recurrence of bottoming out or lateral displacement.
As a result of this new device, we have been gratified to have had patients come from across the country for mesh repair. My office has established relationships with local hotels, limousine services and restaurants to provide a stress free, convenient alternative to patients interested in making the trip for repair. Most patients stay for several days to a week and many combine the trip with a visit to Chicago – an easy 30 minute drive.
So far, I am the only surgeon doing the mesh repair. I am in talks with several large medical device companies who are interested in commercial manufacturer and distribution of the device but, this is likely several years away. My hope is that eventually, patients will have this option available to them from their local plastic surgeon and that some patients at higher risk will even have the option of mesh placement at the time of their augmentation.