Dr. Alejandro Nogueira's Case #UZ6IXUTU

To begin with the fundamentals, the patient should have never been operated via inframammary crease; she had large areolas which sufficed for the access of any kind of implants; instead, the surgeon used the submammary fold incision which, in this case of submammary crease raise, ended in fully abdominal region, something easily avoidable and preventable with the areolar access.

Then, the round implants in a patient who was so slim and skinny who, furthermore, sought large size, was an extremely poor aesthetic judgment option, probably due to poor surgical training, ending in this fake watermelon effect look.

The implants were not latest generation ones of highly cohesive gel; skinny patient should rather be operated with modern ultracohesive gel filled implants to that rippling is minimized; due to this there is evident rippling which substantially downgrades the outcome, a real problem in this case.

Now regarding the finesse of the surgical planning we find the main source of deformities in this case, which is the failure to follow a three dimensional anthropometric strategy to choose the dimension of the prostheses; probably the surgeon had in mind, could only manage or lazily took the easy way to choose large implants, as requested by the patient, ignoring the minimum size customization in them, by simply looking up in the catalogue the cc or gr of them, and not taking into consideration the, also catalogue available, their reference nominal dimensions as per manufacturer specifications; breast implants should never be chosen by their gravitational attraction of the amount of space they may occupy, but based on their real Euclidean dimensions, which are the spatial axes of height, width and depth, like any object, to carry ahead a three dimensional construction fitting like a glove the real anatomical dimensions taken on the patient's chest, which is the so called theoretical maximum mammary base available for positioning the prostheses.

The three dimensional canonical limits to occupy with the breast implants and, therefore, to choose the suitably sized prostheses are, superiorly the third rib or the alternative limit calculated as superior pole edge; inferiorly the inframammary crease or the newly planned one, should it be lowered by having short or pinched submammary pole or be the implants quite large; medially the inner breast ligaments and the osseous creases of the ribcage marking the beginning of the cleavage or the newly planned one; laterally a must, the edge of the ribcage at the flank or, should it be agreed with the patient due to having too lateral breasts, a slightly exceeding point beyond; finally the anterior limit of depth or projection, depends how one can consider this axis, should be the one building the actual and real breast increase wished by the patient.

In this case the implants do massively, grossly, largely and indisputably exceed those five limits, leading medially to symmastia, inferiorly to bottoming out, laterally to side boob deformity, superiorly to high riding implants and anteriorly a massive oversizing beyond patient's wishes, actually the patient was very unhappy with the excessive volume.

Due to gravitational reasons and also due to the differential resistance of every pole's skin the implants migrated inferiorly over the months, leading to a predominance of the bottoming out and alleviating the high riding problem.

As a direct and evident consequence of the former the implants did lose their centricity according to the nipple areola complex, becoming largely eccentric inwards and downwards on the right breast and outwards and downwards on the left one; this can be clearly noticed by the landmark inframammary scars belonging to the first intervention; also the nipples were pointing exactly to the opposite direction of the migration of the implants, since inwards migration or symmastia entails outwards nipple orientation and the downwards bottoming out leads to star gazing nipples.

Due to the aforementioned phenomena there is a problematic over dissection and over growth of skin at the outer, lower and medial poles of the breasts, which need to be reattached to the ribcage, being the perfect candidate for a multipoint capsulorrhaphy which allows both redefinition of the prosthetic pockets and eradication of the over expanded excess of skin; due to the particularities of the case and in order to prevent a new failure of adhesion, the patient opted for polyurethane coated implants which provide the highest grade of tissue adhesion from them all in the market thanks to their bio velcro effect, anatomical shaped and cohesive gel filled, significantly smaller than the previous ones due to express patient request.

This scenario is the revision mammoplasty surgeon's worst nightmare; a multipoint capsulorrhaphy has to reattach the skin back to the ribcage from the armpit at 2 o'clock to the 5 o'clock in order to correct the side boob deformity excessive pocket; from 5 o'clock until 8 o'clock to raise and rebuild a new inframammary crease; finally the symmastia is corrected with capsulorrhaphy from 8 to 10 o'clock; between 10 and 2 o'clock the skin freefall makes a natural redraping effect so that no capsulorrhaphy is ever required; these revision capsulorrhaphies and other revisional techniques have to be performed via areolar approach to obtain full visualization and complete access within the breast pocket.

The capsulorrhaphy entailed a vertical row of anchors at the inner and outer sides of the pocket to redefine, respectively, the cleavage and the side of the breast mound, from the 3rd to the 6th rib arcs and another horizontal row of anchor sutures redefining the submammary crease; anchors are separated between them 10 to maximum 15 mm, otherwise they could fail or leave hammock effects between their gaps.

The combination of custom resized ultracohesive prostheses, the multipoint capsulorrhaphy and the highly adhesive polyurethane coated implants lead to an impressive result, full correction of cleavage symmastia and side boob deformity, no recurrence of the bottoming out and perfect centricity of implants beneath the nipple areola complex, without any kind of nipple orientation distortion, rippling or round fake effect.