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Can excessive breastfeeding be the cause for the upside-down rotation of a breast implant? A case report.

Breast implant malposition is recognized more and more as a complication of breast augmentation and implant-based breast reconstruction. The defined etiologic factors include technical inaccuracy during surgery due to overand inadequate dissection of the pouch and an unsuitably large implant choice. In addition, the patient’s own breast tissue should be compromised to support an implant in the placed position. The aim of our study is to report the first case in which a breastfeeding mother presented with upside-down rotation in the vertical axis of the prosthesis. In addition, the prevention of implant rotation is discussed. A 32-year-old patient had bilateral submammary breast augmentation with 235-mL textured round silicone implants (Silimed; Silicone e Instrumental Médico Cirúrgico e Hospitalar Ltda., Rio de Janeiro, Brazil) for cosmetic reasons. She got pregnant 3 years postoperatively and breastfed for about 2 years. She noticed a deformity in the left nipple areola compared with the right side. The left nipple was more flattened, and she presented to our plastic surgery clinic in February 2011. She was a smoker with no significant medical history. There was no major trauma, intense physical effort, or any other recognized cause except for breastfeeding. The left breast examination revealed a flat anterior surface of the implant and a more grossly deformed, inferiorly facing breast relative to the right, all suggestive of implant rotation (Fig. 1a). Magnetic resonance imaging was undertaken and confirmed it as a prosthesis rotation. When the treatment options were explained to the patient, she decided on implant removal with breast ptosis deformity correction surgery. With the patient under general anesthesia and using the old inframammary scar, both submammary implant pockets were opened. The breast implants were intact with capsule stage Baker I–II. The affected implant in the left side had rotated 180 around the vertical axis (Fig. 1b). The right side was normal. There was minimal fluid present. There was no evidence of capsular disruption. The implant was removed, and it seemed to be intact macroscopically. The capsule was excised. In the same session mastopexy correction was done. The postoperative period was uneventful. Postoperative hematoma and seroma may contribute to infection, capsular contracture, or both, which lead to rotation of prostheses. In addition, a report of 132 cases of primary augmentation discovered that a surgical pocket that is outsized could lead to implant rotation, which occurred in six of 132 cases. No identifiable etiology could be found in our case except the minor trauma caused by continual suction of the infant for 2 years. Round implants were used as the typical breast implants until the introduction of anatomic implants. Because of their symmetrical shape, rotation was not a problem with round implants. In contrast to the literature, in our case it was a round implant that had rotated. Baeke reported that a 14% spin rate occurs in anatomic implants and stated that the nipple areola complex (NAC) is the visual sign of implant rotation. In our case the NAC appeared to be more flat compared with the normal side. One hypothesis about implant rotation is the absence of development of connective tissue that acts as an adhesion layer. Without this layer, which lies between the implant and the capsule, the implant can move freely in the pocket. In our opinion, breastfeeding may be the cause of the degradation of our patient’s existing connective tissue. However, there are no reports so far in the English literature of upside-down implant rotation on the vertical axis in breast-augmented breastfeeding mothers. Other causes that contribute to the possibility of rotation of prostheses have been hypothesized in the literature. After submuscular augmentation mammoplasty, capsular fluid, which may persist for weeks, may be a cause of implant rotation; this can be avoided by routinely using small suction drains postoperatively. Double capsules, capsule within a capsule, periprosthetic mesh, and prosthetic massage also have been stated as possible contributors to implant rotation. An implant positioned in the submuscular plane is vulnerable to the dynamic action of the muscle, which may induce the implant to move laterally or vertically. In re-operation following the rotation of an implant, a partial capsulectomy should be performed to reposition the implant and thus improve prosthetic adherence. Inserting the new anatomic implant into the old capsule could result in a lack of adherence and can lead to a rotational relapse.