Efficacy of Neopectoral Pocket in Revisionary Breast Surgery

Methods 

A retrospective chart review was conducted of 198 consecutive patients who underwent revisionary breast augmentation/mastopexies with conversion to a neopectoral pocket during a four-year period (June 2004 to March 2008). Patients treated for rupture or size change were not included. Only charts with complete operative reports or those in which the replacement implant location could be definitively ascertained as being neopectoral were included in the study. Data were collected regarding the original augmentation date, original implant location (submuscular), revision date, type of implant used for revision, incision used in revision, length of follow-up, and any complications that ensued.

In brief, a neopectoral pocket was developed in each patient, as previously described.1 Most of the procedures were performed in the same manner—though an inframammary fold (Figure 1, A)—although some of the patients required a concurrent mastopexy. After the incision was made, electrocautery dissection was performed in a supracapsular plane immediately superficial to the anterior capsule (Figure 1, B). The implant was then removed through an incision into the anterior capsule (Figure 2, A). Taut caudal retraction of the anterior capsule and elevation of the overlying pectoral muscle can assist with additional dissection, if necessary (Figure 2, B). The capsule was then examined and the old pocket was sutured using interrupted silk or Vicryl sutures (Figure 3, A). The drain and implant were placed and the incision was closed (Figure 3, B). The clinical results are shown in Figure 4, Figure 5.

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Figure 1. A, Revisionary breast surgery is approached through an IMF incision, unless there is the need for concurrent mastopexy. B, The neopectoral pocket is dissected posterior to the pectoralis major and anterior to the existing capsule (implant present).

Reprinted with permission.2

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Figure 2. A, Removal of the implant following establishment of the neopectoral pocket. B, Neopectoral and old implant pockets are shown in relation to one another.

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Figure 3. A, Obliteration of the old implant pocket. B, Placement of the implant into developed neopectoral pocket and complete closure of incision.

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Figure 4. A, C, Preoperative views of a 49-year-old woman presenting with marked double-bubble breast deformity. B, D, Thirteen months following a single operation after revisionary breast surgery; the neopectoral pocket was utilized, with non–form-stable textured gel implants.

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Figure 5. A, C, Preoperative views of a 46-year-old woman presenting with severe capsular contracture and implant displacement. B, D, Fifteen months following augmentation mastopexy with a neopectoral pocket and form-stable, highly-cohesive gel anatomic implants.

Reprinted with permission.2

All patients received perioperative antibiotics, with the majority receiving first-generation cephalosporin. All surgical wounds were irrigated with a solution consisting of 50000 U of bacitracin, 1 g of cefazolin, and 80 mg of gentamicin in 500 mL of normal saline,4 and the implants were bathed in the same solution before insertion into the new pocket. The implants were handled as little as possible in order to to minimize possible contamination.

Results 

A total of 198 patients were identified who met all the criteria for this review. The average time from initial operation to revision was six years, two months. The average time for follow-up after pocket conversion was at least 12 months for all patients (average 26.2 months; Table 1). Presenting complaints are summarized in Table 2. Among the 198 patients, 45 patients (23%) with previous subpectoral implants were noted to have implant rupture at the time of revision.

Table 1. Time interval for conversion and follow-up

		Total
	No. of patients	198
	Time to revision, months	78
	Follow-up, months	26.2

Table 2. Presenting clinical signs

	Clinical signs	No. of patients
	Capsular contracture	138
	Implant malposition	15
	Bottoming out	26
	Symmastia	21
	Total	198

Among the 198 patients with previously subpectoral implants, 128 patients had saline implants, 52 patients had silicone gel–filled implants, and 18 patients had double lumen implants. Among the 45 cases of ruptured implants, 12 of these patients with double lumen implants had only the saline component ruptured; six patients had both components ruptured. The remaining patients had silicone gel ruptures. None of the patients with ruptured implants had any preoperative complaints or physical findings suggestive of implant rupture.

Seventy-one patients (36%) had replacement with silicone gel–filled implants (nine smooth, 62 textured) and 127 (64%) had replacement with form stable, highly cohesive silicone gel–filled implants (Table 3). Complications included three patients (1.5%) requiring reoperation, two for a hematoma and the other for an implant malposition (Table 4).

Table 3. Types of implants used as replacements

		Total	Silicone gel–filled	Cohesive gel
	Total	198	71	127
	Textured	189	62	127
	Smooth	9	9	—

Table 4. Complications

	Complication	No. of patients
	Hematoma	2
	Seroma	0
	Implant malposition	1
	Implant rupture	0
	Infection	0
	Total	3

Of 198 patients, 193 (97.5%) were assessed as having soft implants with a Baker class I of capsular contracture at final follow-up; three patients (2.5%) had Baker class II contractures. No patient had a Baker class III or IV classification postoperatively (Table 5, Table 6, Table 7, Table 8).

Table 5. Preoperative and postoperative Baker classification of patients with originally subpectoral saline implants

		Percent of patients
	Baker classification	Preoperative	Postoperative
	I	10.2%	98.4%
	II	20.3%	1.6%
	III	57.8%	0%
	IV	11.7%	0%

Table 6. Preoperative and postoperative Baker classification of patients with originally subpectoral double lumen implants

		Percent of patients
	Baker classification	Preoperative	Postoperative
	I	5.6%	100%
	II	11.1%	0%
	III	50.0%	0%
	IV	33.3%	0%

Table 7. Preoperative and postoperative Baker classification of patients with originally silicone subpectoral implants

		Percent of patients
	Baker classification	Preoperative	Postoperative
	I	15.4%	98.1%
	II	23.1%	1.9%
	III	50.0%	0%
	IV	11.5%	0%

Table 8. Preoperative and postoperative Baker classification in all patients

		Percent of patients
	Baker classification	Preoperative	Postoperative
	I	11.1%	97.5%
	II	20.2%	2.5%
	III	55.1%	0%
	IV	13.6%	0%

Among the 198 patients who had a neopectoral pocket conversion, 56 had concurrent placement of acellular dermal product and 94 patients required a concurrent mastopexy (Table 9). The differences in complications or Baker classifications between the patients who had either acellular dermal product or a concurrent mastopexy were not statistically significant when compared to patients who did not.

Table 9. Augmentation versus augmentation mastopexy

		No. of patients
	Augmentation	104
	Augmentation/mastopexy	94
	Total	198

Discussion 

This experience with 198 patients who uniformly had their breast deformities successfully corrected with a site change to a neopectoral pocket provides reassurance that all implant complications can be corrected with this procedure. This experience also confirms that neopectoral positioning can be highly successful in achieving results with a low risk of capsular contracture. This is particularly remarkable in this series because all of the patients already had established capsular contracture and therefore could rightly be considered to be at higher risk for capsular contracture at reoperation.

It is also of interest that the majority of the implants used in the reoperation were textured devices, which might cause us to rethink the role of these implants in “redo” surgeries. All of the silicone gel–filled implants used in these patients were either Natrelle (Allergan, Irvine, CA) or Mentor implants (Mentor, Santa Barbara, CA), both of which have been recently approved for clinical use by the US Food and Drug Administration (FDA).5, 6 The form-stable, highly cohesive silicone gel–filled implants were style 410 implants (Allergan), which are available in the United States under the auspices of studies sponsored by the FDA.7 These implants are currently pending FDA review.

Recently, as a result of the aforementioned moratorium on silicone gel–filled implants and the subsequent trend toward large saline implants and submuscular implantation, revisionary surgery for volume-depleted breasts has become necessary. Rarely do physicians see patients for revisionary surgery with existing subpectoral saline implants who still have adequate superficial soft tissue. Therefore, maintaining the bulk of the pectoralis muscle over the implant is desired.

To address that issue, we developed our neopectoral pocket site change technique. In it, we create a new subpectoral plane that allows for continued use of the existing capsule.1 The neopectoral pocket is deep to the pectoralis major, but superficial to the anterior capsule, which is left intact, because removing it would have the untoward consequence of further tissue damage. In addition, it would necessitate the use of even larger implants to fill an expanded pocket. As we outlined in our previous article, the advantages of creating a new pocket (instead of performing a total capsulectomy) are reduced trauma, ease of dissection, increased precision in the dissection with regard to the inframammary fold (IMF) for a “double-bubble” deformity or inferior implant displacement, and increased precision with medial and lateral dissection for correcting either symmastia or lateral displacement, respectively.

Ideally, this procedure can also aid in preventing capsular contracture. With a new, vascularized pocket, increased adherence to the textured surface of the new implants, regardless of whether they are round or anatomic, can be achieved. The precise development of this pocket is essential to a good outcome when inserting anatomic implants; using this method, the pocket should be “snug” against the implant to prevent rotation and optimize adherence.

The neopectoral pocket technique will also provide an additional option for surgeons treating secondary implant-related complications and will simplify the management of complex problems (Table 5, Table 6). This report lacks sufficient statistical power to prove that textured devices improve rates of capsular contracture, so larger, multicenter trials are needed to provide further data. It is of interest to report that we have had decreased rates of capsular contracture with the addition of acellular dermal matrices to our revisionary surgeries. We have previously reported our findings8 that the combination of all advanced modalities aids in possibly minimizing capsular contracture.

Conclusions 

The development of a neopectoral pocket is a new type of site change operation. This procedure is designed to address many of the issues in revisionary aesthetic breast surgery that challenge surgeons today. Neopectoral pockets can also be used for the revision of implant-based reconstructed breasts. The technique will become increasingly important with anatomic implants, because both the “virgin” tissue and “snug” pockets can be achieved with a neopectoral pocket site change. Although other techniques may work in some (or even most) patients, based on our results, the technique we describe is straightforward, anatomic, precise, and highly successful in correcting iatrogenic breast deformities while avoiding other deformities and complications.