Miller, Jonathan E. M.D.; Goodreau, Adam M. M.D.; Blanchet, Nadia P. M.D.
Plastic and Reconstructive Surgery: December 2020 – Volume 146 – Issue 6 – p 835e-836e
Breast augmentation remains one of the most popular cosmetic procedures today, with over 300,000 performed in 2018. In this same year, almost 30,000 patients underwent implant removal, a roughly 40 percent increase from 2008.1 This trend echoes growing public concerns regarding breast implant–related illnesses as recently outlined in a special topic review by Rohrich et al.2 There is undoubtedly a growing population in both reconstructive and cosmetic settings seeking consultation for breast implant removal, often with specific request for capsulectomy.
In the cosmetic patient presenting for explantation, the challenge of preserving breast aesthetics following total capsulectomy is uniquely linked to implant position. Subglandular implant placement is potentially the most perilous variation because of an amalgamation of effects exerted by the prosthesis on the surrounding tissues. Implant placement above the pectoralis results in glandular atrophy.3 Similarly, the absence of muscular support leads to ptosis of the skin envelope. Following capsulectomy, these skin flaps frequently resemble nipple-sparing mastectomy flaps with blood supply primarily through the subdermal plexus.
Previous literature has revealed the pitfalls associated with lifting the breast following nipple-sparing mastectomy. Davies et al. found that Wise and vertical patterns had increased wound healing complications versus periareolar incisions.4 Variations of an omega incision have been described in this context. Santanelli di Pompeo et al. used a double-mirrored omega pattern after skin-sparing mastectomy with decreased rates of skin necrosis versus a Wise-pattern incision.5
The omega lift can be performed alone [see Figure, Supplemental Digital Content 1, which shows preoperative (left) and postoperative (right) photographs of a patient undergoing subglandular implant removal and capsulectomy with an omega lift without new implant placement, http://links.lww.com/PRS/E275] or over a new implant [see Figure, Supplemental Digital Content 2, which shows preoperative (left) and postoperative (right) photographs of a patient who underwent removal of subglandular implant with capsulectomy and an omega lift over new implant in the subglandular plane, http://links.lww.com/PRS/E276], and in conjunction with fat grafting. It is designed along a horizontal axis centered on a superior periareolar incision (Fig. 1, left). Following total capsulectomy, tailor tacking is performed and skin excess resected superior to the nipple-areola complex such that the breast envelope and nipple-areola complex are appropriately positioned on the chest wall. The skin between the superior and inferior limbs of the omega pattern can be deepithelialized for autoaugmentation of the upper (Fig. 1, center) or lower poles. We advocate placement of quilting sutures between the breast envelope and the chest wall to prevent migration of the nipple-areola complex, to control postoperative ptosis, and to minimize risk of seroma formation.
Fig. 1.: (Left) Breast augmentation with Regnault grade II ptosis with markings for omega lift (blue line). (Center) After removal of breast implants by means of incision along the superior limb of the omega pattern. Removal of the breast implant reveals more severe ptosis and thinned soft-tissue envelopes similar to mastectomy flaps. Here, the skin inferior to the incision is deepithelialized and used to autoaugment the upper pole. Alternatively, the incision could be made along the inferior limb of the omega pattern (not shown) to allow the deepithelialized tissue to augment the nipple-areola complex. The nipple-areola complex will be repositioned with the skin closure, as shown by the arrow. (Right) Final closure with correction of ptosis and an omega-shaped scar.
Implant removal by means of total capsulectomy in the subglandular augmentation patient presents a technical challenge because of the profound effects of the implant on both the gland and overlying skin envelope. A complication of skin flap necrosis is devastating in any patient but can be distinctly so in the cosmetic patient population. The omega lift has been validated in the setting of breast reconstruction in high-risk patients. Although the debate over the safety of breast implants continues, so will the high incidence of patients seeking explantation after cosmetic breast augmentation. For those patients with prior subglandular augmentation with atrophic glandular tissue and thin ptotic skin envelopes, it is our experience that the omega lift yields a safe and aesthetic result.