Dr. Alejandro Nogueira's Case #9HJMZCIC

To begin with, this was not at all an easy case of breast augmentation since the patient was severely hypoplastic with barely any breast tissue, very slim, actually could be considered of skinny frame; such cases require maximum technical precision because any suboptimal adjustment is going to be obvious and noticed as unsightly effects; unaware of this circumstance and or insufficiently skilled to face this patient's case challenges, the previous surgeon carried ahead a very poor surgical work.

The implants were inserted via the inframammary crease, however no one mandatory correction of its level was foreseen or planned, so the incision was performed on the original inframammary fold and not in the new one created by well centred prostheses; the consequence was terribly eccentric implants, riding too high and the nipples pointing downwards; subsequently there is a derivate issue after achieving correct centricity of the breast implant beneath the nipple, since this centricity requires lowering the inframammary crease to a desired level compatible with perfect implant placement and lower pole fullness, thus being the previous incision made too high leads to the new inframammary crease be lower than the initial incision such scar will not be at the correct and concealed crease but in the middle of the lower pole of the breast, this is unavoidable however would have never happened if the incision would have been through the areola, even in cases of prosthetic eccentricity repair like this.

Other major deformity was the dynamic animation muscle flex deformity, due to the use of a submuscular or dual plane with insufficient release of the pectoralis muscle; such a basic mistake is unacceptable and can't be understood like any kind of muscular intolerance or individual idiosyncrasy, it is a well known issue and preventing it is also widely known, the pectoralis muscle needs extensive release not to lead to embracement or incarceration and dragging of the implant.

Additionally the implants were chosen with their base width too narrow without any anatomical criterion according to patient's ribcage dimensions, and they were of round profile which is not the best choice in general breast augmentation but much less or even unwise in skinny patients; all the former lead to a coconut or fake balls look, extremely wide cleavage separation and bottom level outcome.

Revision mammoplasties are of very high difficulty in skinny patients with ruptured or aged implants, because the cover is poor and sometimes unreliable, the vascularity scarce, the visibility of any tiny lack of prosthetic adjustment total, they lack support for plasties and other revision techniques and the mandatory capsulectomy or periprosthetic capsule removal is a very delicate maneuver due to having such thin mammary tissue supply above the implant.

The patient was given two options for the surgical access, going through the areola, thus having both the areolar and the lower breast pole incisions, or avoid the areolar scar by means of horizontally extending the previous submammary scar; she opted for the latter very much aware of its visibility and eager to prevent any additional scars at the areola; renewal of implants, especially aged ones or suspected or purportedly ruptured, requires a mandatory total capsulectomy, which is unfeasible via short submammary incisions, this maneuver needs short areola incisions or long inframammary ones, the patient preferred the long scar underneath the breast.

This case was managed with a complete, meticulous and very delicate capsulectomy, during which all the calcifications were removed, the aged prosthesis explanted and their leaking silicone totally eliminated to obtain a healthy and fleshy bed of tissues to host the new implants.

Then the pockets for the implants were redefined, the inner cleavage and the inframammary creases mobilized and expanded to achieve good nipple areola complex centricity, and new implants were inserted in the ideal subfascial plane of placement.

Note that in the subfascial plane it is physically, anatomically and literally impossible any kind of animation or muscle flex deformity.

The new implants were chosen state of the art highly cohesive gel filled, anatomical shaped and macrotextured at the shell, chosen with better suited dimensions, wide enough to the patient's frame, optimizing the lower pole and the cleavage, achieving an amazingly natural look and increasing the volume to a moderate size based on patient's wishes.