Are permanent sutures to rib cage necessary for repair of over dissected pocket? Does capsuloraphy always involve that? (Photo)

Question

I am waiting to have my breast pocket repaired as my surgeon over cut me and one breast is much lower than the other. I am 4 months PO and will likely wait a full year to redo, but I am in need of other opinions re: how it will be fixed. Is stitching to the ribcage cartilage typically done in a first time attempt at repairing a breast pocket made too large? There seem to be many varying opinions regarding repair, and I would love to hear as many of those as possible. Thank you

Paul E. Chasan, MD, FACS · Answer

inferior and/or lateral malposition of breast implants is very common. As a breast revisionary specialist, I perform capsulorrhaphy on a weekly basis. I actually wrote the first "how to do it" article in our journal. Almost never do you need to suture to rib. There many important technical aspects to get it right including a "mirror image capsulotomy" and performing the procedure in a sitting position. You should be able to get a very nice and symmetric result. Best wishes.

Farbod Esmailian, MD · Answer

Judging by your photos your right breast is slightly bottomed out but the left breast is also sitting too high.  I would suggest as you have pointed out, you need to wait some time to allow the dust to settle.  At that point, the right crease can be elevated with capsule tightening, capsulorrhaphy.  I generally use permanent sutures for this but there is no need to suture to the ribs or rib cartilage.  In certain severe cases textured implants can be used and/or acellular dermal matrix (strattice) will help keep the fold and prevent recurrence.The left breast I would want to make sure you don't have capsular contracture as it does seem a bit high and not centered on the nipple and areola complex.  Hope that helps.

William Andrade, MD · Answer

Thanks for your question.  I personally do all of my capsulloraphies with dissolving sutures, and usually I am very satisfied with the outcomes.  However, there are a wide range of techniques to do this procedure.

Shaun Parson, MD · Answer

Thanks so much for your question.  It is not necessary to place sutures in the actual ribs.  You will need to have a procedure called a capsuloraphy performed.  That is a procedure where the scar tissue that naturally forms around your implant is change in some way so that the implant sits in a higher position.  One way to do that is by sewing the capsule to itself (you can anchor the capsule to your own ribs but it is not the only way to do the surgery).  A newer (stronger and often more dependable way) is to use an artificial material called Dermal Replacement Material.  There are a number of different types of material that can be used but it basically acts like an internal bra or "hammock" to support the breast.  I would suggest going to see a surgeon who specializes in this type of surgery so you don't have to have multiple attempts to correct your current situation.  Hope this helps.

Wesley G. Wilson, MD · Answer

Hi,
You certainly have some asymmetry post op.  It appears by the photo that the right side is a little low but the left side is also a little high.  Suturing capsule to capsule should be able to "tack up" the right side.  You may want to consider lowering the left so that the nipple sits just a little more centered also.  Good communication with you surgeon is key to getting the revision right.  
Best wishes,
Dr Wilson

Tom J. Pousti, MD · Answer

I am sorry to hear about/see the problem you are having after breast augmentation surgery. I think your concerns are appropriate; one of your breast implants does seem to sit quite low on your chest wall, consistent with breast implant displacement ("bottoming out”).I think you will benefit from revisionary breast surgery which will likely involve capsulorraphy ( internal suture repair). In my practice, this "repair" involves a 2 layer permanent suture approximation of capsule to capsule tissue; suturing to the rib cage is not necessary. Sometimes, depending mainly on the patient's history and physical examination, I will also use additional supportive materials such as acellular dermal matrix or biosynthetic mesh. This procedure serves to reconstruct the lower poles of the breasts and prevent migration of the breast implants too far inferiorly. Associated issues with positioning of nipple/areola complexes should improve with this operation.  
Make sure that the plastic surgeon who does this procedure for you can demonstrate significant experience with revisionary breast surgery. 
I hope this, and the attached link and video (dedicated to corrective surgery for bottoming out concerns), helps.

Jon A. Perlman, MD (retired) · Answer

I routinely have used slowly dissolving sutures with the addition of external support taping for about 6-8 weeks.  I avoid actual suturing of the cartilaginous rib and instead use the adjacent soft tissues.  I also agree that slight lowering of your higher side may be indicated and helpful.  
Jon A Perlman MD FACS 
  
Certified, American Board of Plastic Surgery 
  
Extreme Makeover Surgeon ABC TV 
  
Best of Los Angeles Award 2015, 2016 
  
Beverly Hills, Ca

Ronald V. DeMars, MD (Retired) · Answer

I rarely find it necessary to suture to cartilage, but the occasion does sometimes arise. The heavier the implant the more difficult to get a simple capsulorrhaphy to hold. Sometimes an ADM insert is required.

Are permanent sutures to rib cage necessary for repair of over dissected pocket? Does capsuloraphy always involve that? (Photo)

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