Breast Revision Using ADM (Acellular Dermal Matrix)? (photo)

Thank you very much for this thought provoking question.  I'm assuming your capsular contracture is on the left, although you did not state that.  I would agree with your second doctor that you need silicone implants and some form of lift.  Another piece of information that we would need to know in order to give you a complete answer would be, are your implants above or below the muscle.  If they are above the muscle, then pocket switching would certainly be useful.  ADM has been given very good ratings for decreasing the chance of capsular contracture in a recurrent situation; however, there are no guarantees on the subject.  From your comments, it would appear both of the plastic surgeons you consulted with recommended a lift, which I totally agree with.

One other modality that you have not mentioned would be the use of Accolate.  This should definitely decrease the chance of re-encapsulation, and I recommend that you use this prophylactically starting two days after surgery.  There have been many good papers on the subject and under these conditions, it would probably be an appropriate adjunct to your post-surgery game plan.

Hello! Thank you for your question!  Given your history as well as symmetry and shape issues, consideration for pocket revision is reasonable.  A capsulorrhaphy would be needed for revision of your breast pocket. If you do need such, the use of a dermal matrix or mesh may be considered if your tissue now has significant laxity that is failing in support or a significant deformity in which recreation of the breast pocket is required along with adding additional support and coverage of the implant.  Certainly, the larger the implant, the heavier the weight...thus, it may be useful to consider placement of a matrix or mesh.  Otherwise, capsulorrhaphy for pocket revision using your native tissue should suffice.  It has been used safely and effectively to correct synmastia, restore the inframammary fold, mask implant issues (e.g., rippling, wrinkling, etc.), support the implant within a "sling", and improve aesthetic results in revisionary breast implant and reconstructive procedures.  However, only by physical examination would one be able to make recommendations on the benefits over the risk of using a matrix or mesh in your situation. Consult with a plastic surgeon well-versed in breast procedures who will assist you in deciding which procedure(s) will be the right for you.  Best wishes!  Hope that this helps!

Although difficult to give you an accurate recommendation without a proper examination, I would say that to address your capsular contracture is one thing, doing an implant revision is another.To address your capsular contracture, using an ADM is a new way to treat this problem and it may be successful. Another option is to reposition your implant into a new pocket (go from submuscular to subglandular or vice versa)Changing implants to a different profile or going from saline to silicone and moving your nipple is about changing the appearance of your breasts and it is unrelated to addressing your capsular contracture.

Acellular dermal matrix  has become popular as a way of dealing with implant encapsulation. I have no experience with it, but I have heard it is quite successful in preventing recurrent encapsulation.  There are some other considerations, however.  A lift with  new silicone implants and ADM is going to be  a pricey  undertaking.  Plastic surgeons seem to be a little overly anxious to jump on the ADM bandwagon, not knowing  what the long term implications are.  I would probably opt for a simple  capsuletomy and implant replacement.  A lift would be optional but not absolutely necessary.

Hello,

I believe you've posted before, no? I disaggree with both doctors.  High profile implants will give you a ballish look like a contracted implant, especially if your tissues are thin.  In addition, they cause more long term thinning of your tissues, and are more likely to drop down out of the cover of your muscle, kind of where your implants are now.  It is in vogue to use these implants because the companies push them, and surgeons are not aware of their long term effect.

ADMs are great devices and they have enabled reconstructive surgeons to perform one stage breast reconstruction with incredible beauty and a natural appearance.  There has been a transfer over to the cosmetic usage of ADMS with reinforcing breast implant capsules for support and to minimize rippling.  There is most recently talk of using them for recalcitrant capsular contracture.  My feelings are that they are unnecessary and overly expensive (more than a pair of silicone gel implants).  Adhering to the principles of placing a new, properly sized, moderate profile implant in the submuscular position after a true total capsulectomy will likely halt recurrent capsular contracture most of the time.  The addition of a leukotriene inhibitor like Singulair or Accolate might be considered.  However, Accolate exposes you to a small but real risk of liver toxicity, so I only use Singulair.

Looking at your photo shows that your implants are in a low position and have dropped into the sagging portion of your breast.  Removal of your implants with the entire capsule, replacement with new, moderate profiled implants with a 'no touch' technique, followed by a formal mastopexy will produce a result that will look pretty and will likely not recontract.

Best of luck!

These implants look as though they are above the muscle from the appearance in the photo. You would be well served by having them replaced in the submuscular position. A breast lift is highly recommended.

Contractures recur at quite a high rate, and the early reports with ADM (acellular dermal matrix) seem to show that this material decreased the chances of recurrence. 

I tend to agree with the suggestion that you switch to silicone. As far as profile of the implant goes, I would make that determination comparing the width of your breast and the size of the implants and choose the profile closest to your breast width.

Thanks for the question, best wishes.

Based on your photos, it appears you have some encapsulation on your left side.  With a revision plan I would like recommend removal of your implants with a total capsulectomy (removal of current scar tissue) and placement of new implants ideally into a virgin pocket (that has not seen any scar tissue formation).   In addition, I would likely recommend a breast lift to address your ptosis.  Since this is the first time you are experiencing hardening of your 11 year old implants, I would not likely recommend ADM at this time.  Alloderm (ADM) is a good option for internal support of an implant and there is growing evidence that ADMs help slow down the process of capsular contracture.  However, ADMs are expensive. I generally reserve Alloderm (ADMs) for cases of recurrent capsular contracture.  Hope this helps.

Dr. Basu

Houston, TX

From your story and the photo, it appears that you have aged implants and the capsule most notably on the left. There is no absolute answer to your question unfortunately. You do need a lift on both sides and once the capsules are removed this will be even more evident. The ADM would be used to help support the implant after the capsule removal as well as help limit the potential for reformation. The ADM is a great tool, but also expensive as a result, not everyone will use it for the first sign of a capsule. If you can afford the cost, it has been shown to not only help support the implant but also limit the capsule reformation in the future. 

Best of luck,

Vincent Marin, MD
San Diego Plastic Surgeon