Challenging breast surgery cases

1) Capsular contracture


Α) A rare complication that may occur after breast augmentation.

We do not know its exact cause. The main hypothesis as to its cause and pathogenesis claims that this is a biological response to the implant (foreign body) leading to the formation of a capsular contracture around the implant. In capsular contracture, the reaction produces collagen fibres, fibroblasts and fibromyoblasts on the capsule. This becomes hard and is often painful.

Some factors such as subclinical inflammation, biofilm formation (bacteria on the implant surface), bleeding during surgery, incision location, implant pocket location, may increase the possibility of capsular contracture formation, however, there is no specific explanation as to its exact causes. Roughly, capsular contracture is classified in four Grades.

GRADE A : The patient does not feel anything but, during palpation, the doctor can identify tissue hardness.

GRADE B : Patient can feel a slight firmness of the breast.

GRADE C : The breast becomes firmer and starts to change in shape.

GRADE D : All above symptoms along with painful breast.


The only treatment is surgical. 20 to 30 years ago, surgeons would try to break the capsule by pressing hard against the breast, but this technique is now strongly denounced.


Patient submitted to breast augmentation 5 years ago. She noticed that her left breast has started to change in shape and felt firmer. The patient’s implant was under the mammary gland.


1) Access through previous incision.

2) Implant removal.

3) Creation of new pocket beneath the pectoralis major muscle. (there are several indications suggesting that capsule formation is reduced when the implant is placed under the muscle.)

4) Use of rough surface implants (associated with less chances of capsular contraction.)

5) Suturing of the pocket.

6) Incision closure.

7) Result is full correction of the breasts.

8) How can we restrict capsular contracture:

  1. By placing the implant either under the muscle or by using the subfascial or dual plane technique
  2. Rough surface implants suggested most suitable
  3. Inframammary incision
  4. Non touch- No pain technique in surgery
  5. No bandages or tight bras or massage on the breasts after surgery

2) High-riding of implants

hrImplants that are mispositioned higher than normal. Implants placed under the muscle can rarely be mispositioned higher up the chest.



Treatment is only surgical.

1) Planning of correct implant position.

2) Access through previous incision

3) Implant removal (no need to change the implant)

4) Preparation of down-facing pocket if needed

5) Implant placement

6) Suture

7) Results

3) Tuberous Breast


What is a tuberous breast?

The Tuberous or Tubular Breast is a congenital (birth) abnormality of the breast shape. There are several theories that try to explain how this condition occurs, but the exact cause is yet unknown.


Patient submitted to breast augmentation.

Case: Patient with non-identified tuberous breast is seen with 1) double-bubble deformity 2) large areola 3) pocket deformity.

Surgical approach

This is among the toughest cases we are called to treat

Surgery stages - diagnosis


1) Pocket

2) Lower quadrant of the breast

3) Areola

Surgical treatment

1) Incision around the areola – periareolar

2) Implant replacement

3) Pocket change from inframammary to M.U.S.T.

4) Release of entire breast

5) Vertical and horizontal lines to expand the inferior segment of the breast as this is a tuberous breast case


6) Placement of new implants

7) Lifting and correction of the areola with a special technique, the “tobacco pouch” and special permanent suture CV-3

8) Correction of right breast on the operating table

9) Left breast is not yet corrected

10) Same procedure is repeated for left breast

11) Correction of both breasts

12) First day post-op. Red-orange stain is Betadine

13) 6 months post-op

14) Results at 8 months post-op

15) Result comparison

Read more about tuberous breasts here


4) Double-bubble

dbA rare complication seen following breast augmentation. Patients present with two parallel, transverse and curved folds along the lower pole of the breast that correspond to the breast and the silicon implant. Although the cause of this complication is yet to be clarified, surgeons believe that this is due to either a downward shifting of the implant, a capsular contraction or a ptosis of the breast. It is more often seen in cases of tuberous breasts, small breasts with disproportionately large implants, breasts with small areola to inframammary fold distance, breasts with large inframammary fold. There are several ways to correct this malformation. The most popular approach is capsulorraphy that allows the implant to shift to a normal position.


35-year-ole patient with double-bubble deformity following left breast augmentation.


1) Planning of new implant position.

2) Access through previous incision.

3) Implant removal

4) Capsule suture with permanent internal stitches and restriction of previously enlarged area.

5) Result correction.

Another way to correct the double-bubble deformity is to create a new pocket between the pectoralis major and the anterior capsule. We then close the old pocket with stitches and place the implant in the new pocket.

3 Months after



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