Breast animation deformity is a known complication associated with submuscular and dual-plane implant placement for breast reconstruction. Patients experience visible contraction and lateral displacement of their breasts with any movement of the pectoralis major muscle. This can be aesthetically displeasing and can cause significant pain. Until recently, the prevalence has been grossly underestimated. A recent study found 100 percent prevalence of animation deformity in a 25-patient cohort with prior submuscular prosthetic breast reconstructions; 80 percent of patients were bothered by their deformity and 28 percent sought revision operations.1
Current techniques for managing this complication include the following: botulinum toxin injection into the pectoralis,2 reoperation with biplanar pectoralis major splitting,3 reoperation with subcutaneous acellular dermal matrix placement, and reoperation involving implant pocket change into the prepectoral plane.4 Reviewing the previous literature on this subject, we found that all patients who underwent reoperation, regardless of technique, experienced a complete resolution of their animation deformity without evidence of recurrence. With botulinum injection, most patients saw temporary improvement; however, few experienced permanent resolution.
Our group has observed similar outcomes within our own practice, attaining transient improvement with botulinum and complete resolution with operative intervention. Our current preferred method for addressing this complication involves removal of the previous implant(s) with complete periprosthetic capsulectomy, transfer and refixation of the pectoralis major into its original anatomical position on the chest wall, and new implant placement in the prepectoral plane. This technique has evolved to include complete circumferential acellular dermal matrix implant coverage, for minimization of capsular contracture in the new subcutaneous pocket.5
Between March of 2016 and March of 2017, we performed 22 revision reconstructions on 12 patients with significant animation deformity following their initial breast reconstruction. Nineteen of the initial reconstructions had been two-stage expander/implant-based reconstructions, and three were single-stage, direct-to-implant reconstructions, all with partial muscular coverage performed at the time of mastectomy. Three patients underwent postreconstruction radiation therapy. All patients complained of significant pain and deformity with voluntary pectoralis major muscle contraction (Fig. 1).
All revision reconstructions were performed by the senior author (H.S.). Fifteen revisions involved prepectoral pocket change with complete acellular dermal matrix coverage; seven were performed with prepectoral pocket change alone. Drains in the acellular dermal matrix group were left in place for approximately 20 days postoperatively. There were no instances of delayed healing, infection, or wound breakdown. One patient required evacuation of a hematoma on postoperative day 7 after restarting her preoperative anticoagulant. One patient who had not undergone acellular dermal matrix coverage experienced significant capsular contracture, requiring subsequent capsulectomy with implant exchange. No patients in either group experienced recurrence of animation deformity (Fig. 2).
Animation deformity remains an underreported complication of submuscular breast reconstruction, causing significant distress in patients following their reconstruction. Repositioning the pectoralis major into its anatomical position and changing the implant pocket to the prepectoral plane can alleviate the pain and deformity associated with this complication. In an effort to avoid this problem, we have begun performing the majority of our primary breast reconstructions in the prepectoral plane with complete anterior acellular dermal matrix coverage.
Dr. Sbitany is a consultant for LifeCell, Inc. The remaining authors have no commercial associations or financial interest to disclose related to the content of this work. No funding was received for this article.
Rachel B. Lentz, M.D.Merisa L. Piper, M.D.Clara Gomez-Sanchez, M.D.Hani Sbitany, M.D.Division of Plastic and Reconstructive SurgeryUniversity of California, San FranciscoSan Francisco, Calif.
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