45-54 year old woman treated with Nipple reduction Surgery

*Treatment results may vary

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A woman in her early 50’s who came in to evaluate her implants and also to address problems with her nipples. She initially had surgery 26 years earlier and reports significant bruising afterwards, followed by a fairly rapid development of hardness around her implants. The hardness of the implants (capsular contracture) made it uncomfortable to lie on her stomach. She was also bothered by “long nipples” that were overly prominent in her clothing. She wears silicone nipple shields to hide them. They are also very sensitive in the shower and against her clothing. Given the length of time since her original surgery I obtained an MRI which showed that both implants were ruptured. Decisions to make: Replace or remove? She likes filling her bra without the padding and wants to replace the implants. Saline or silicone? Her tissues are thin, and she does not want the additional wrinkles and ripples which may be more noticeable with saline implants. Keep the implant above the muscle or place it below the muscle? She does not want to see motion of the implants when she tightens her pectoralis muscles (animation) and would prefer to keep the implants above the muscle. Our usual decision would be to place the implants in contact with fresh tissue in a new plane below the muscle but I felt that I might be able to make a new space between the implant capsule and the muscle ( a “neosubcapsular” space) so the implants would be in contact with fresh tissue but still above the muscle. Texture or smooth surface? Texture can decrease dropping and lateral shifting of the implant with time but can increase the risk of late seroma and pseudocapsule formation. Because she is so physically active, she would theoretically be more at risk for seroma and pseudocapsule with the texture so she elected for the tradeoffs of the smooth. Size? She is 5 1 ½ and 118 lbs. Her operative report was obtained and listed a 175 cc implant on her left and an adjustable implant on her right but did not mention its size. After discussion of the options she elected for 250 cc implant on her left, which we sized her in the office by adding 75cc sizing shell to her existing breast so she could see how this looked in a bra. Our plan was to have a range of sizes available for the right side and to decide in the operating room. Choice of nipple reduction procedure: The “standard” approach that is taught is to amputate the top of the nipple and let this heal in. Although this does reduce the height of the nipple papule it cannot reduce it’s diameter. We elected for a top hat flap procedure, which does not leave any raw areas to heal in and also reduces the diameter and height of the nipple papule. Remove and replace the implants immediately or leave them out for 3 months before replacing? Capsular contracture can be difficult to treat, and can havea high recurrence rate with immediate replacement of the implants- as high as 70% in some studies. The causes of capsular contracture are still being debated. A common cause may be biofilm, where bacteria gets on the implant and “walls itself off” (like tartar on your teeth that the dentist scrapes off) so that the body can’t fight it. In a situation like this, simply replacing the implant does not give the body a chance to clear the bacteria and the risk of it spreading to the new implant and causing a contracture is high. I have had the best success in these cases by leaving the implant out for 3 months prior to replacing it. But a hematoma (collection of excessive blood around the implant) can also stimulate a capsular contracture and given her history of significant bruising after her original surgery this seemed more likely in her case. I am not as worried then about immediate replacement of the implant and this is what she elected. Surgery: Her old scars were two fingerbreadths above her existing inframammary fold and were felt to be too high and had not healed satisfactorily. I felt it best to place new incisions in the proper location along her existing inframammary fold and this was discussed and approved by her. I was fortunately able to develop a neosubcapsular pocket, below the old breast capsule but above the muscle. In this way the implants could be kept in the subglandular position as per the patients request, but in a new “space” in a fresh plane of tissue. The ruptured implants were removed. The 250 cc round smooth moderate profile plus silicone gel implant was placed on her left, and was best matched with a 275 cc round smooth moderate profile silicone gel implant on her right. She is now seen nearly 3 months after surgery. Although it is early, her breasts have remained soft and she can now lie comfortably on her stomach. She has not lost nipple sensation, but no longer has the hypersensitivity in the shower and from her clothing.