Dr. Alejandro Nogueira's Case #K6XWB4GM

The medical history begins with a poorly planned and worse executed breast augmentation via inframammary crease and in the partial submuscular plane or also called dual plane; when the dual plane is carried out the pectoralis muscle has to be disinserted or freed from the ribs at its lower edge attachments in order to allow the creation of the prosthetic pocket, therefore the muscle loses one of its insertions on the ribs, however there is another muscular attachment exactly at this same lower end, of non mechanical role as long as the attachment to the ribs stays intact.

This ligament joins the lower end of the pectoralis muscle to the breast skin; contraction of the pectoralis does not produce any problem there in the non operated patient or the subfascially operated one given the lower end of the muscle stays firm and static during its contraction, unless the pectoralis had been freed from the rib like in the dual plane which makes the muscle glide free upwardly without restrictions during its contraction and therefore pull from the skin creating the dynamic double bubble deformity or animation flex deformity.

During any partial submuscular or dual plane breast augmentation the lower end of the pectoralis muscle has to be separated from the ribs, which is correct and even essential, but necessarily and mandatorily the lower end of the pectoralis muscle has to be also separated from the mammary skin; failing to perform the latter creates the animation flex deformity because the muscle shrinks its lower end during contraction and pulls the breast from its lower pole attachment to the pectoralis.

As simple as it sounds to prevent it, as easy as it seems to treat it; whenever a dual plane technique is performed the surgeon can't forget to separate the lower end of the pectoralis muscle from the breast skin and not only from the ribs, and in breast revisions suffering this animation deformity the treatment is as easy as separating the skin and the muscle, just it, either in submuscular or subfascial plane of location; needless to say this complication is anatomically impossible in the subfascial plane of placement, regardless the knowledge and skills of the surgeon, since the pectoralis is not released from the ribs and then its anatomy and functionality remain unaltered.

This particular case suffered from this terrible technical failure after her first mammoplasty, during which the surgeon failed to prevent the animation flex deformity; furthermore, the surgeon wasn't only unable perform a correct and preventing technique, additionally he did not understand what was causing the dynamic deformity and how to correct it; what is more unacceptable, the patient was told the problem happened to be in her atypical muscular anatomy and no specific solution was given.

As further aggravating factor the patient was very unhappy because her implants were excessively wide and created a side boob deformity and a non tolerated lateral prominence of the implants, plus a cleavage tenting close to become symmastia.

The patient, in her desperation, sought second opinion for revision with another surgeon who did neither understand the obvious causes and the easy treatment of the animation muscle deformity; this surgeon carried out a breast explantation, this means definitive removal of the prostheses, since this surgeon also believed the patient had peculiar anatomy or atypical muscular structure making her intolerant to the presence of the breast implants, something absolutely false in each and every patient suffering this complication.

The only option applied to the patient was a definitive removal of the breast implants without the required and mandatory periprosthetic capsulectomy, and a partial replacement of the breast volume injecting fat in the breasts by the so called breast fat transfer or lipofilling, a treatment against which here we would like to warn the patients because of its risks, complications, long term effects, interference with breast diagnosis and unknown although suspected health risks, besides the disappointing when not fraudulent augmentation effects, short lasting in time, limited in size and random in shape.

As a consequence of the explantation and lipofilling the breasts developed massive fat necrosis, cysts of steatonecrosis, chronic pain, nodules and redness, ending in a stabilized situation with several lumps of necrotic fat within which required removal, with no one actual gram of breast augmentation.

If at least the patient would have got the benefit of eradication of the animation flex deformity she'd even be happy about the decision to explant the prostheses; however and as it can be understood from the previous explanations, after removal of the breast implants the dynamic deformity during muscular contraction of the pectoralis muscle remained the same or somehow aggravated; now the deformity was not a cleft lower pole and a double bubble deformity, since there was no longer any implant, after the explantation it was the whole breast mound en bloc which was massively raised; this can be noted in the preoperative images where the patient is contracting the pectoralis muscle, paying attention to the distance between the raising inframammary crease and the original incision made for the augmentation and explantation; the displacement of the breast was massive during muscular contraction.

Breast implants removal is not the solution for the animation flex deformity, actually it can even worsen it; this case is good proof of that.

Without releasing the adhesion of the lower end of the pectoralis muscle with the mammary skin the animation flex deformity finds no correction; there is absolutely no other technical solution to this issue; on the positive side it can be said that correction of the animation deformity is a foolproof maneuver with total rate of success; once freed from the muscle the mammary mound does not follow the pectoralis during contraction, end of the problem.

This patient opted for a custom inframammary incision using the original scars and an additional extension of them to allow full capsulectomy and removal of the remains of fat; few steatonecrosis cysts were very near the skin at the upper and inner quadrants of the breasts, which were causing pain, deformity and worries to the patient; she requested their removal by means of direct incisions above them, which allowed the extraction of the necrotic fat.

Then it was performed full release of the pectoralis muscle from the mammary skin and gland, which was terminating and corrective of the dynamic animation of the breasts; a subfascial pocket plane was created and new implants, anatomical shaped, cohesive gel filled and macrotextured were inserted right beneath the nipples, this means very lateral as the patient was born with quite lateral breasts which is a conditioning obligation, however with the right dimensions to allow optimal breast fullness without uncomfortable nor unsightly deformities.

The remarkable breast asymmetry was managed using different bases, heights and projection in the nominal reference dimensions of the mammary prostheses.

Very important note: the odd ordinal number before and after results images shown are taken with the patient in a relaxed attitude, no muscular contraction is exercised and the pectoralis is totally loose without active support from the muscle; to the contrary the even ordinal number before and after results images shown are taken instructing the patient to perform her maximum pectoralis contraction; no trace of animation flex deformity persists after the revision with proper muscular release and new implants, this time successful ones.