Breast Surgery
Preoperative Saline Implant Deflation
in Revisional Aesthetic Breast Surgery
Aesthetic Surgery Journal
2015, Vol 35(7) 810–818
© 2015 The American Society for
Aesthetic Plastic Surgery, Inc.
Reprints and permission:
[email protected]
DOI: 10.1093/asj/sjv081
www.aestheticsurgeryjournal.com
Cindy Wu, MD; and James C. Grotting, MD, FACS
Abstract
Background: Preoperative saline deflation is a clinically useful intervention in revisional breast surgery. It allows suspensory ligament recovery, reveals
true glandular volume, and simplifies mastopexy markings. Presently unknown are the volumetric changes that occur after deflation.
Objectives: The authors report the three-dimensional (3D) changes that occur with preoperative deflation prior to revisional breast surgery.
Methods: We reviewed available charts of revisional breast surgery patients who underwent preliminary saline implant deflation. Our protocol is
deflation 4 weeks prior to revision. Three weeks following deflation, the patient is evaluated to finalize the operative plan, including the need for implants,
mastopexy, and adjunctive procedures. A subset underwent 3D imaging to quantify the volumetric changes over the 3-week deflation period.
Results: Between 2002 and 2014, 55 patients underwent saline implant deflation prior to 57 revisional surgeries. Seventeen were revised without implants and 40 with implants. The 3D subset of 10 patients showed a mean 15.2% volume increase and 0.18 cm notch-to-nipple distance decrease over
the 3 weeks following deflation and prior to definitive surgical correction.
Conclusions: Breast volume increases and the notch-to-nipple distance decreases during the 3-week interval prior to reoperation. This “elastic breast recoil”
occurs after the mass effect of the implant is removed, resulting in recovery of stretched suspensory ligaments and gland reexpansion. We believe 4 weeks is
optimal for gland normalization. Ideal candidates include patients requiring secondary mastopexy without implants, implant downsizing in the same pocket, and
secondary augmentation mastopexy. Preoperative saline deflation and 3D analyses are useful for preoperative planning in reoperative breast surgery.
Level of Evidence: 4
Accepted for publication April 1, 2015; online publish-ahead-of-print June 2, 2015.
During the silicone moratorium in the United States, breast
augmentation was performed primarily with saline implants,
which is why US plastic surgeons often encounter saline
implants during revisional breast surgery. A couple decades
after their augmentations, often following children and
weight gain, these patients frequently present with macromastia or ptosis, the desire for a smaller implant or implant
removal, and at times, deformity from capsular contracture
and asymmetry. The challenge for the revising surgeon is
determining the true operative needs of the patient and the
operative plan. This is directly related to the volume and
shape of the native breast, which can be obscured by underlying capsular contracture or malposition of the implant.
Preoperative saline deflation takes the implant volume and
shape out of the equation, and helps the surgeon visualize
the native breast tissue without implant distortion. This facilitates accurate preoperative planning and prevents potential
Therapeutic
sequelae from unanticipated changes that might occur in the
gland beyond the control of the surgeon, leading to the need
Dr Wu is an Assistant Professor, Division of Plastic and Reconstructive
Surgery, University of North Carolina, Chapel Hill, North Carolina, and
a Next Generation Editor for Aesthetic Surgery Journal. Dr Grotting is a
Clinical Professor, Division of Plastic Surgery, University of Alabama at
Birmingham, Birmingham, Alabama; a Clinical Professor, Division of
Plastic and Reconstructive Surgery, University of Wisconsin, Madison,
Wisconsin; and is the CME/MOC Section Editor for Aesthetic Surgery
Journal.
Corresponding Author:
Dr James C. Grotting, Grotting and Cohn Plastic Surgery, One
Inverness Center Parkway, Suite 100, Birmingham, AL 35242, USA.
E-mail: [email protected]
Presented at: the American Society for Aesthetic Plastic Surgery annual
meeting in San Francisco, CA in April 2014.
Wu and Grotting
for additional revisions. Deflation is particularly useful
when a smaller implant is needed. After a period of deflation, the capsule contracts and becomes smaller, permitting
a more exact fit of the smaller implant into the pocket
without the need for extensive capsulorrhaphy.
We began preoperative saline deflation in 2002, and observed that after a period of deflation, the breast envelope
appeared to tighten and the parenchyma re-expanded.1 We
hypothesized that this “elastic breast recoil” occurred after
the mass effect of the implant was removed, allowing
recovery of stretched suspensory ligaments and gland
re-expansion back toward its pre-augmented volume (Figure 1).
After the trial deflation period, we arbitrarily developed
a protocol to bring the patient back to the office 3 weeks
following deflation to finalize the operative plan, including
the need for implants, mastopexy, and adjunctive procedures. We tried to limit the total period of deflation to
4 weeks in order to minimize inconvenience to the patient.
As we gained experience, we found deflation to be a clinically useful tool, and applied it to more patients. What we
did not know was the ideal time period prior to secondary
surgery to perform deflation and the precise volumetric and
shape changes that occurred in the interim. We therefore
studied all of our revisional breast patients who have undergone preoperative saline deflation to determine their outcomes. To further quantify the clinical phenomenon of elastic
Figure 1. Elastic breast recoil. (A) The interstitial pressure of
the saline implant exerts outward force (black arrows) onto the
breast parenchyma (green arrows) which also exerts pressure
onto the implant and skin envelope. (B) After saline deflation,
the interstitial pressure exerted by the saline implant onto the
parenchyma (black arrows) drops, and the parenchyma is able
to re-expand back towards its pre-augmented volume (green
arrows).
811
breast recoil, we then examined a subset of patients with 3D
imaging to quantify the volumetric and shape changes.
METHODS
A retrospective 12-year chart review, from January 2002 to
March 2014, of the senior author’s revisional aesthetic
breast surgeries, was performed to identify patients who
had preoperative saline implant deflation. All patients who
underwent preoperative saline implant deflation and had
normal preoperative mammography reports were included.
Patients were excluded if they had undergone preoperative
silicone implant explantation, had incomplete records, or
did not obtain preoperative mammography reports. We did
not routinely require patients to provide postoperative
mammography reports unless they had further revisional
breast surgery at least 1 year after their index procedure.
When this was required, we collected the reports, but did
not require patients to provide mammography images. All
patient identifiers were removed and data stored on-site
with a password-protected drive. Since this was a retrospective chart review of a single surgeon’s experience intended
for clinical teaching purposes, this study was exempt from
Institutional Review Board approval. Our standard procedure is to deflate saline implants 4 weeks prior to definitive
revisional breast surgery (Supplementary Video 1). The
volume of saline removed is recorded and compared to the
operative note or, if not available, the patient’s history. This
volume aids determination of the final implant size. At 1
week prior to surgery, the patient is evaluated to determine
the final operative plan, including the need for implants,
mastopexy, and adjunctive procedures such as fat grafting.
At that time, the patient is asked, “In a shaping bra, are you
satisfied with the volume of your breast?” If she is satisfied
with the volume, then she is offered either: (1) removal of
the deflated saline implant alone; or (2) removal of the deflated saline implant and mastopexy with or without fat grafting.
If she wants to be larger than her native breast volume, then
she is offered: (1) removal and replacement with implant
(often smaller than the implant that was explanted) and mastopexy with or without fat grafting; or (2) removal and
replacement with or without fat grafting. In cases where the
patient needs an implant for upper pole fullness, but has
excessive lower pole breast tissue, we offer a removal and
replacement with implant, and a small reduction (addition/
subtraction mastopexy). After determining the patient’s
goals, implants are ordered if needed (Figure 2).
Three-Dimensional Volume Measurement
A subset of patients had preoperative three-dimensional
imaging (Vectra, Canfield, Fairfield, NJ) at three time
points: at the initial consult (Time 1), immediately after
deflation (Time 2), and 3 weeks after deflation (Time 3).
Time 3 is 1 week before revisional surgery. Analyses of
Aesthetic Surgery Journal 35(7)
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Removal With No Implant Replacement
If no implant is needed, then mastopexy and fat grafting are
performed as described above after closing down the
capsule with 2-0 Vicryl (Ethicon, Somerville, NJ).
RESULTS
Figure 2. Preoperative saline deflation algorithm. FG, fat
grafting.
breast volumes and breast landmarks at these time points
was performed and the time interval between Time 2 and
Time 3 was recorded.
Removal and Implant Replacement
Using prior incisions, the submuscular capsule around
the deflated saline implant is entered and the device is
removed. Capsulectomy is performed only if the capsule is
thick or calcified. Capsulorraphy is performed as needed to
close down the submuscular capsule if a smaller implant is
replaced into the submuscular space. If a pocket change to
a subglandular pocket is chosen, then careful pocket dissection is carried out to accommodate the smaller implant.
If a mastopexy is needed, the nipple areolar complex (NAC)
is tailor tacked to the previously-marked position and adjusted as needed with the patient upright. A skin-only mastopexy is then performed if the upper pole volume is
sufficient. If the upper pole is deficient, a superiorly-based
parenchymal flap or fat grafting can be used to enhance the
upper pole volume. We advocate a vertical approach for
mastopexy as previously described.2-4 This flap is used only
when there is greater than 50 grams of tissue in between
the medial and lateral pillars, as we have found that
volumes less than 50 grams do not make a significant difference in enhancing upper pole volume. The pocket type is
chosen based on the breast volume to implant ratio. If the
patient has chosen smaller than a 250 mL device, and has
pinch thickness >2 cm, then typically a textured round silicone implant is placed in the subglandular pocket. If a
superiorly based parenchymal flap is needed, it is tucked
underneath the gland, and on top of the implant. If the
patient has chosen an implant larger than 250 mL, placement in the subglandular plane risks implant edge palpability, and it is our preference to place the implant in the
submuscular plane. In this case a smooth round device is
chosen. In general, our preferred implant volumes are
smaller with augmentation mastopexy than with augmentation alone.
All patients were female, and the average age was 43.7
years (range, 17-68 years). Out of 55 patients, eight had
capsular contracture, and of those, four had Baker IV capsular contracture (Figure 3). Fifty-five patients underwent
57 revisional breast surgeries following saline implant
deflation. Seventeen procedures were performed without
the use of implants: one with removal only, nine with concurrent mastopexy, two with fat grafting, two with mastopexy and fat grafting, and three with additional reduction,
mastopexy, and fat grafting. Forty procedures required an
additional implant: thirteen had replacement with an
implant only (three whose previous implant volume was
unknown, eight with smaller implants, two with larger implants); nineteen had removal, replacement, and mastopexy (one whose previous implant volume was unknown,
seventeen with smaller implants, and one with larger implants); three had removal, replacement, mastopexy, and
fat grafting (two with smaller implants, and one with larger
implants); four had addition, subtraction, and mastopexy;
and one had addition, subtraction, mastopexy, and fat
grafting (Table 1). After an average follow-up of 447 days
(range, 1.2 years), there were no deflation-related complications. Specifically, there were no infections from deflated
saline in the capsule, no psychological sequelae from the
period of deflation, and no failures to proceed with revisional surgery. We require a commitment of payment in full at
the time of deflation. There were three complications
overall after revisional surgery: one patient had unilateral
deflation of a saline implant requiring replacement, another
had a minor wound dehiscence that resolved with wound
care, and the last patient required a left periareolar mastopexy performed under local anesthesia.
Three-Dimensional Imaging Subset
A subset of 10 patients underwent 3D imaging at three time
points: at the initial consult (Time 1), immediately after
deflation (Time 2), and 3 weeks after deflation (Time 3).
Using the Sculptor (Vectra, Canfield, Fairfield, NJ) program,
breast landmarks were placed by hand, rather than by the
computer automated landmarks, on the following landmarks:
sternal notch, clavicles, nipples, apex of the areola, lateral
inframammary fold (IMF), medial IMF, and IMF at the breast
meridian. In order to eliminate the intra-observer variability
of placing the breast landmarks, these landmarks were placed
at three separate times, and the average of these values
were recorded. To calculate volumes, the Analysis program
Wu and Grotting
813
Figure 3. This 49-year-old woman presented 8 years after subpectoral saline augmentation and presented with bilateral Baker 4
capsular contracture as well as the desire for a smaller implant. (A, D, G) Initial presentation. (B, E, H) Immediately post-deflation
(400 cc from the right and 400 cc from the left). (C, F, I) Eighteen months postoperative removal and neosubpectoral placement of
Mentor (Mentor, Minneapolis, MN) textured 250 cc moderate plus silicone implants, vertical mastopexy, and 60 cc of fat grafting
to each side. ( J) Intraoperative view demonstrating the immediate on-table result, as well as the explanted saline implants and corresponding capsules.
(Vectra, Canfield, Fairfield, NJ) was used because, unlike the
Sculptor measurement of volume, the Analysis program takes
into account chest and abdominal wall irregularities.
Comparison of Volumes Between Time 2 and Time 1
The calculated volume difference between the initial
consult (Time 1) and immediately post-deflation (Time 2)
was recorded for each breast as “Δ volume T2 – T1.” These
volume differences were then compared to the actual deflation volume and the patient-reported volume of their saline
implants (Table 2). Of note, in our earlier patients, the
volume removed was not consistently documented in the
chart, and is referenced as “N/R” or “not recorded.” In
patient 2, the volume for the right and left breast by Vectra
Aesthetic Surgery Journal 35(7)
814
Table 1. Types of Revisional Breast Surgeries
Procedure without implants
Number (n = 17)
Removal only
1
Removal and mastopexy
9
Removal and fat grafting
2
Removal, mastopexy, and fat grafting
2
Removal, reduction, mastopexy, and fat
grafting
3
Procedure with implants
Number (n = 40)
Removal and replacement
Previous implant volume unknown
3
With smaller implant
8
With larger implant
2
Removal, replacement, and mastopexy
Previous implant volume unknown
1
With smaller implant
17
With larger implant
1
Removal, replacement, mastopexy,
and fat grafting
Previous implant volume unknown
0
With smaller implant
2
With larger implant
1
Addition/subtraction and mastopexy
4
Addition/subtraction, mastopexy, and fat
grafting
1
Total
57
was calculated as 70.9 and 446.7 mL; the actual volume
removed was 50 and 450 mL. For patient 5, the Vectracalculated volume difference was 388 mL and 355.1 mL;
the actual volume removed was 400 and 325 mL.
Comparison of Volumes Between Time 3 and Time 2
These patients showed an average 15.45% (16.9% on the
right and 14.0% on the left) increase in volume, as well as
a decrease in the sternal notch-to-nipple distance of 0.18 cm
(0.06 cm on the right and 0.3 cm on the left), over an average
of 31.5 days of deflation (Figures 3 and 4, Supplementary
Figures 1 and 2, Table 2, Supplementary Videos 2 and 3).
DISCUSSION
We first began preoperative saline deflation in 2002—
publishing select cases starting in 20071-6—as a method to
determine whether an additional implant or mastopexy
only is necessary in revisional breast surgery. In the context
of removing silicone implants during the moratorium,
Rohrich et al7 observed a rebound increase in breast volume
over the initial 3 months, “most likely secondary to the
natural restoration of the previously compressed breast
tissue with a subsequent gain in superior fullness.” Four
options were available to the patient: (1) saline implant exchange; (2) explantation alone; (3) breast contouring with
saline implantation; and (4) breast contouring alone.
Many women with saline implants may eventually seek
revisional breast surgery. A common challenge in secondary
aesthetic breast surgery is determining the true volume of the
breast parenchyma versus that of the implant. Accurate
assessment of parenchymal volume is important in determining whether the patient needs additional volume (another
implant) or less volume (reduction) in conjunction with a
mastopexy. A distinct advantage of saline implants is they can
be deflated preoperatively to determine the true parenchymal
volume. This was described by Fischman8 in 2003. He deflated the implants right before surgery to facilitate preoperative
marking. In Zaworski’s9 reply, he noted a 5-7 cm upward migration of the NAC after removal or deflation of subglandular
saline implants. His algorithm was to remove the deflated
saline implants 2-3 months prior to definitive mastopexy to
allow the skin to contract. We started our saline deflation in
2002, but were unaware that others would publish their experience in 2003. Handel10 described postoperative saline deflation after secondary augmentation mastopexy in order to
decrease tension and improve circulation to skin flaps to
avoid a complication. However, the duration of deflation, or
the quantitative volumetric and shape changes that occur in
the interim, have never been previously described.
After reviewing our 3D imaging data, we were able to
quantify the clinical phenomenon of elastic breast recoil.
Breast volume appears to increase on average 15.2% after
saline implant deflation in the 3 week interval prior to reoperation. While this increase occurs in both the upper and
lower pole, in some patients it is most noticeable from the
basal view (Figure 5 and Supplementary Videos 2 and 3). A
possible explanation for this is shortening of the suspensory
ligaments that have previously been stretched by the implant,
with resultant expansion of the gland back towards its preaugmented volume. Another explanation could be that after
the implant is deflated, the pressure from the implant onto
the parenchyma decreases. This drop in the parenchymal interstitial pressure allows fluid to reenter the interstitial tissue,
much like a sponge absorbing water, to fill in the dead space
left after implant deflation. Del Vecchio11 describes this phenomenon as a drop in “subcutaneous tissue pressure” after
implant removal that makes the SIEF method (Simultaneous
Implant Exchange with Fat) possible.
This phenomenon of “elastic breast recoil” is important
to note prior to secondary breast surgery. For example, if
the revisional plan included removal of the existing saline
Wu and Grotting
815
Table 2. Three-Dimensional Imaging Volumes
Patient
Number
Age
(Years)
Chief
Complaint
Pre-deflation, Time
1 (cc)
Right
Left
Immediately
Post-deflation,
Time 2 (cc)
Volume Decrease
From Time 1 to
Time 2 (cc)
Patient-reported
Volume, Implant
Only (cc)
Actual Deflation
Volumes, Implant
Only (cc)
One Week
Preoperative
Volume, Time
3 (cc)
Right
Left
Right
Left
Right
Left
Right
Left
Right
Left
Volume Change
From Time 2 to
Time 3 (%)
Sternal
Notch-to-Nipple
Distance
Change From
Time 2 to Time
3 (cm)
Right
Left
Right
Left
1
37
Ptosis,
macromastia
567.7
608
166.4
245.6
401.3
362.4
350
375
N/R
N/R
194.1
263.5
16.6
7.3
−0.4
−0.6
2
51
Unanticipated
deflation
(right),
macromastia
498.6
855.1
427.7
408.4
70.9
446.7
375
375
50
450
431.1
430.7
0.8
5.4
−1.2
−1
3
41
Ptosis,
macromastia
527
504.9
204.4
185.9
322.6
319
350
360
N/R
N/R
251.6
174
23.1
−6.4
0
4
27
Macromastia
607.8
685.3
100.2
89.6
507.6
595.7
575
580
N/R
N/R
151.2
161.7
50.9
80.5
0.8
5
61
Ptosis
847
776
459
420.9
388
355.1
400
400
400
325
422.6
415.3
−7.9
−1.3
−1.2
−2.6
6
59
Baker grade 4
capsular
contracture
773.7
618.9
301.5
270.1
472.2
348.8
325
325
215
215
270.4
307.1
−10.3
13.7
−0.7
−0.6
7
42
Capsular
contracture
514.8
422.8
229.8
188.4
285
234.4
Unknown
Unknown
300
300
254.4
185.2
10.7
−0.2
0.7
0.7
8
44
Unanticipated
deflation (left)
380.9
284
68.1
88.7
312.8
195.3
Unknown
Unknown
300
150
108.1
96.8
58.7
9.1
−0.3
−0.5
9
48
Unanticipated
deflation (left)
761.3
568.6
563.3
530.1
198
38.5
Unknown
Unknown
200
a
582.3
539.3
9.8
1.7
0.55
10
46
Capsular
contracture
668.1
697.6
240.6
226
427.5
471.6
480
480
440
440
281.6
294.8
17
30.4
1.2
16.9
14.0
−0.06
MEAN
−0.3
1
−0.2
1.1
−0.3
On average, the breast volume increases 15.2% (16.9% on the right, and 14.0% on the left); and the notch-to-nipple distance decreases 0.18 cm (0.06 cm on the right and 0.3 cm on the left) in the 3-week interval.
N/R, not reported. aThis patient had fully deflated spontaneously, so no more deliberate deflation was performed in the office.
implants, replacement with a smaller silicone implant, and
a vertical mastopexy, there are several considerations.
Using a smaller silicone implant will not elongate the
sternal notch-to-nipple distance as much as a larger
implant. The addition of a vertical mastopexy will further
shorten the notch-to-nipple distance. The safe way to approach this would be to make conservative vertical mastopexy markings in the preoperative area and then, after the
smaller implants are in place, perform a simulated stapled
mastopexy and adjust the nipple height intraoperatively.
However, despite this careful tailoring, the nipples may still
end up too high. We hypothesize that this is due to the
“elastic breast recoil,” and that the notch-to-nipple distance
will decrease when the larger implant is removed in the
process of gland normalization. Just as in breast reduction,
when weight is removed from the breast, the nipples
elevate. In breast augmentation, weight is added, and the
nipples lower. When a larger implant is replaced with a
smaller one, the breast is unweighted, and the nipples
elevate. This concept of unweighting the breast has previously been described.12 Because these breast changes encompass the whole gland, we thought it would be best to
track these changes with 3D imaging rather than anthropomorphic measurements alone.
We always offer deflation for patients with saline implants before the size change to smaller implants. It allows
the patient to participate in the decision making of how large
they want to be. If they want to downsize, it can be difficult
for the patient to visualize and describe how much smaller
they would like to be, and deflating the saline implant
allows the patient to see how much of their own breast
tissue they have to start with. For patients with silicone implants, we offer a staged approach of explantation then revisional surgery in two instances. First, if there is uncertainty
as to the need for mastopexy, we find that a staged approach
helps clarify the need for mastopexy. Second, we believe
that when there is extracapsular silicone rupture, a staged
approach after complete capsulectomy and removal of extravasated silicone allows the unstable soft tissue envelope
to normalize. A period of waiting allows the blood supply to
the breast to recover, which puts the patient at a lower
risk for ischemic complications. The silicone implants are
removed in the first operation (which is analogous to
in-office saline implant deflation), and 3 weeks afterwards
816
Aesthetic Surgery Journal 35(7)
Figure 4. This 44-year-old woman was initially treated 11 years ago with bilateral augmentation mastopexy using 410 cc smooth
round saline implants. She subsequently developed macromastia with asymmetry of lower pole mass. Additionally, she has widened
nipple areolar complexes (NACs) bilaterally. (A, D, G) Initial presentation. (B, E, H) Immediately after deflation. (C, F, I) Eighteen
months after replacement with 225 cc smooth round saline implants, with bilateral reduction (L = 203 grams, R = 115 grams).
we bring them back for final preoperative planning. The
revisional surgery is performed 1 week later. Therefore, our
staged approach is the same for both silicone and saline implants. We find this elastic breast recoil occurs in patients
who have had both silicone explantation and saline deflation, and waiting until this recoil has occurred clarifies
preoperative revisional planning.
One weakness of this study is the small sample size. The
percentage of new revisional breast patients requiring preoperative saline deflation is small, and all of these patients
seen in our practice undergo imaging at these three time
points. We suspect that there has been and will be fewer
women with saline implants requiring revision due to the
increased popularity of silicone implants. We only acquired
the 3D imaging system in December 2013, and since then
have been imaging all of our patients requiring deflation. In
addition, we did not have a non-deflation control group.
We are continuing to accrue patients into our study and
plan to reanalyze our data in the future to see if our results
are statistically significant.
Furthermore, the deflation volumes are approximate, as
the values are measured by looking at the values in the
suction canister. One further consideration for future
studies is to remove this aspirated fluid and measure this
more accurately in a beaker or weigh the saline.
Another weakness is that there is a degree of variability
in the measurements depending on where the breast landmarks are placed by hand. However, we attempted to minimize this variability by taking several measurements and
reporting the average. In addition, volume measurements
were in general more variable as the grade of ptosis increased or when the patient was heavier. This is due to the
fact that the IMF marker cannot be accurately placed if
covered by breast tissue, if the abdominal contour is obese,
or if there are chest wall irregularities. For this reason, we
chose to calculate volumes with the Analysis program
(as opposed to the Sculptor program, which is the program
used to generate breast measurements and select implants
in augmentation patients). Unlike the Sculptor measurement of volume, the Analysis program extrapolates chest
Wu and Grotting
817
Figure 5. Three-dimensional imaging of a 61-year-old woman who underwent the deflation process. This gland recovery is most
noticeable in the basal view. The red arrow indicates the lower pole of the breast. (A) Before deflation. (B) Immediately postdeflation. Note the soft tissue irregularities in the lower pole skin immediately after deflation (red arrow). (C) Three weeks postdeflation. These lower pole soft tissue irregularities (red arrow) have resolved by 3 weeks.
and abdominal wall irregularities and subtracts its volume
from the breast volume. This extrapolation may have a degree
of inaccuracy as well, since it is a computer-simulated
volume. Due to these shortcomings, we use 3D imaging as
an adjunct, and not as an independent tool, for preoperative planning. The deflation volume is also very helpful in
choosing implant size. For example, a patient presents with
macromastia and ptosis, and desires replacement with a
smaller implant with mastopexy. The deflation volume is
350 mL, and 3D imaging shows an increase of 50 mL
from immediately post-deflation (Time 2) to 3 weeks
post-deflation (Time 3). If after 3 weeks she is satisfied with
her breast volume, the deflated implant is removed and a
mastopexy only is performed. If after 3 weeks she wants to
be a little larger, but not as large as before, we would pick
a smaller implant that was less than the prior 350 mL
implant volume (for example, 250 mL) and perform a
removal and replacement with a smaller implant as well as
the mastopexy.
The patients’ ages ranged from 17 to 68 years in the
entire cohort, and from 27 to 61 years in the 3D imaging
subset. We stratified patient age by the percentage volume
change between Time 3 and Time 2, and did not find a consistent relationship. Preoperative mammography images
were not available in all patients, and the density of the
breast is not routinely dictated in the consultation or operative note. For these reasons, we are unable to draw conclusions on the relationship of age and breast density to the
degree of elastic breast recoil.
Lastly, one theoretical confounding variable to volume
measurements could be the presence of a seroma after the
deflation process. In all of our revisions, we have not noted
any significant seroma formation in our patients at the time
of definitive correction and shell removal. In two patients
with heavily calcified capsules, reaccumulation of milky
fluid after deflation occurred within a week. Re-deflation revealed milky fluid (laboratory studies revealed it was a lactocele and not a lymphocele). These patients went on to
revisional surgery without adverse sequelae.
We have not performed these volume measurements at
any other longer or shorter time intervals to compare
volume changes over time. However, we feel confident that
the algorithm that we currently use with 4 weeks of deflation seems to allow the changes to occur without subjecting
Aesthetic Surgery Journal 35(7)
818
the patient to a more prolonged period without definitive
correction. We have considered performing serial imaging
between Time 2 and Time 3 in order to pinpoint the exact
time at which the elastic recoil becomes stable, but this would
place further inconvenience on the patient. The timing of our
imaging, first at the initial consult (Time 1), then immediately
after deflation (Time 2), and then 3 weeks after deflation
(Time 3), coincides with necessary clinic visits. We felt that
additional visits for imaging would have potentially made
patients more self-conscious about their deflated breasts
than necessary. The 2D and 3D images taken immediately
after deflation (Time 2) occur at the same office visit
during which the decision to deflate occurs, and the
images taken 3 weeks later (Time 3) occur during the
office visit for final preoperative planning, thus obviating
the need for an additional clinic visit just for pictures. In
the future, we plan to shorten the interval between Times
2 and 3 to determine the minimal period of deflation
needed to achieve a stable gland.
We feel that the period of deflation has the added advantage of allowing the patient “to get back in touch with her
own body”: that is, to be able to see how much breast
tissue she actually has and whether or not her volume has
changed enough to allow her to get rid of the implants
completely. Many patients are surprised to find that they
don0 t actually need the implants any longer to fulfill their
aesthetic goals. Preoperative saline deflation is easy to
perform and has considerable value for both the patient
and the reoperating plastic surgeon.
CONCLUSIONS
Breast volume appears to increase after saline implant
deflation in the 3 week interval prior to reoperation. A possible explanation for this is shortening of the suspensory
ligaments and recovery of parenchyma that have previously
been stretched by the implant, with resultant re-expansion
of the gland. This “elastic breast recoil” phenomenon is important to note prior to secondary breast surgery. We find
that a 4-week period is optimal for the gland to normalize
prior to definitive correction. Ideal candidates include patients requiring secondary mastopexy without implants,
implant downsizing in the same pocket, and secondary
augmentation mastopexy. Preoperative saline deflation and
3D analysis are useful for preoperative planning in reoperative breast surgery.
Supplementary Material
This article contains supplementary material located online
at www.aestheticsurgeryjournal.com.
Disclosures
Dr Grotting is a shareholder in the Aesthetic Surgeons Financial
Group (Birmingham, AL), which owns CosmetAssure
(Montgomery, AL). He also receives book royalties from Quality
Medical Publishing (St. Louis, MO) and is a shareholder in
Keller Medical, Inc. (Stuart, FL) and Ideal Implant, Inc. (Dallas,
TX). Dr Wu has nothing to disclose.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
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