Munster, Ind. — Placement of a polypropylene mesh sling is a simple and highly effective repair technique for the "bottoming out" of breast implants, and it may also be considered as an adjunct to primary surgery for preventing implant displacement in women at high risk, according to Robert E. Frank, M.D.
(left) Patient with severe bilateral bottoming out. (right) Patient three years after placement of mesh sling.
Dr. Frank tells Cosmetic Surgery Times that he developed the idea for a mesh sling repair several years ago and that, over the past 3½ years, he has performed the repair procedure in about 40 women with breast implant displacement. He recently completed his first case in which it was undertaken as a preventive measure. The results of the repairs have been excellent, and the success and ease of the procedure make it a superior alternative to capsulorrhaphy, says Dr. Frank, a board-certified plastic surgeon in private practice in Munster, Ind.
An alternate solution
"Bottoming out has been such a difficult surgical problem to fix that implant removal without replacement has even been recommended as one solution. However, that is not an acceptable alternative for women who want larger breasts and who have already spent a significant amount of money to achieve their desired appearance," he explains.
"Capsulorrhaphy has been the traditional repair technique, although a failure rate of up to 50 percent has been reported. Compared with capsulorrhaphy, mesh sling implantation is a faster and simpler operation, and when I am finished, I am confident about the quality of the repair. In my experience it has yielded excellent cosmetic results along with high patient satisfaction, and there have been no cases of extrusion, infection or displacement recurrence," Dr. Frank says.
The hernia parallel
Dr. Frank notes that "bottoming out" can occur as an early iatrogenic problem if the surgeon overdissects the pocket so that the implant sits too low. More commonly, however, it develops over time as the weight of the implant overpowers the strength of the existing soft tissue support.
"As women undergoing breast augmentation are now seeking larger and larger breasts and more heavy implants are being used, the frequency of displacement problems is increasing," Dr. Frank says.
He was motivated to develop this repair technique when faced with a patient who presented with what he describes as "the worst bottoming out I had ever seen." Dr. Frank performed a traditional capsulorrhaphy repair, but it failed early. Regarding implant displacement as a situation somewhat analogous to hernia development, Dr. Frank theorized that it might benefit from the same approach to repair.
The drawing demonstrates the placement of the breast implant and mesh sling through a periareolar incision. The mesh sling allows accurate placement of the inframammary crease.
"I knew from my general surgery days that a mesh hernia repair was more effective than a traditional repair performed by suturing the weak tissues together. Therefore, I reasoned that placement of a mesh support would also offer greater long-term success in breast implant displacement repair. The mesh itself serves as a supporting bridge closing the defect caused by the stretched soft tissues. However, it also acts as a scaffold for ingrowth of fibrous scar tissue that increases its strength and further improves its long-term ability to withstand the force exerted by the implants," he explains.