Surgical Correction of Breast Animation Deformity with Implant Pocket Conversion to a Prepectoral Plane.

Abstract

We have read with interest the article by Holland et al.1 on prepectoral conversion as a treatment for animation deformity in patients with retropectoral breast implants. Animation deformity is a breast distortion caused during contraction of the pectoralis major in women with retropectoral implants, which can happen both in breast augmentation surgery and in reconstruction after mastectomy. The incidence of animation deformity varies according to the surgical technique used, reaching 75 percent to 100 percent in reconstructions after mastectomy.2–4 Various methods have been described for treating animation deformity, including selective nerve sectioning, replacing the implants by a muscle flap, conversion according to the split-muscle technique, and that described in the article by Holland et al.1 for prepectoral conversion. This last method is booming, given that it resolves the animation deformity in 100 percent of the cases.5 However, we believe that prepectoral conversion presents some limitations. First, this surgery theoretically restores the function of the pectoralis major by fixing its distal fibers to the chest wall. Nevertheless, the function of this muscle has already been supplied by other muscle groups; therefore, patients typically have no functional limitations. Second, this surgery is not without complications. In fact, Holland et al.1 reported an infection rate of 13.8 percent and a 6.3 percent rate of capsular contracture. Third, the cosmetic results can be suboptimal due to visibility of the implant, requiring revision surgery in 11.3 percent of patients.1 For this reason, Holland et al.1 in their series contraindicate the procedure for those women with a pinch test less than 1 cm who do not have donor fat. They used a biological mesh to cover the implant in 81 percent of patients, and in 52.5 percent, they performed lipofilling before the prepectoral conversion, thereby increasing the costs of the process. We recently treated a 26-year-old patient with retropectoral breast augmentation implants who presented with bilateral animation deformity and had undergone surgery on five occasions in various centers to correct this deformity without success. In our unit, we proposed sectioning the pectoralis major using a transcapsular approach. The surgery consisted of an incision in the inframammary fold, sectioning of the periprosthetic capsule, and withdrawal of the implant. Subsequently, we identified the muscle fibers responsible for the animation deformity using an electrical muscle stimulator (6 Hz; 400 μsec; 35 mA; 1 second of pause and 4 seconds of activity). Once we had performed the sectioning of the muscle fibers, we activated the electrical muscle stimulator to confirm elimination of the animation deformity. Many reasons motivate us to propose this procedure as an alternative for women with retropectoral implants and recurrent animation deformity. First, the technique has lower morbidity compared with prepectoral conversion due to not requiring capsulectomy and a new pocket for the implant. Second, the technique can be performed in patients with scarce subcutaneous tissue. Lastly, the procedure preserves the muscle coverage that provides an optimal cosmetic result because it reduces the implant’s visibility without needing a mesh or lipofilling, which increase the costs and complications of the surgical process. The technique of sectioning the pectoralis major guided by an electrical muscle stimulator should therefore be considered an alternative for resolving animation deformity. Its main advantages are its low morbidity, low cost, and good cosmetic results. However, prospective studies will be needed to assess the results of this technique. DISCLOSURE The authors have no disclosure or financial support to report. Benigno Acea-Nebril, M.D., Ph.D.Alejandra García-Novoa, M.D., Ph.D.Isabel Casal-Beloy, M.D., Ph.D.Breast UnitSurgery DepartmentHospital QuirosanludA Coruña, Spain