Augmentation Mammaplasty after Breast Enhancement with Macrolane

Sir: A 45-year-old woman consulted a dermatologist with the aim of improving a moderate degree of breast ptosis. She underwent bilateral breast augmentation with 250 ml of hyaluronic acid (Macrolane; Q-Med AB, Uppsala, Sweden) to each breast. She presented 6 months later at our medical practice complaining of rapid and asymmetrical volume loss causing worsening of the breast ptosis in association with visible and palpable indurations of the breasts (Fig. 1). The patient was advised to surgically remove the filler and was offered concurrent implant-based augmentation mammaplasty. The patient was scheduled for surgery 6 months after the consultation, 12 months after the Macrolane injections.Fig. 1: Preoperative view of the breasts showing breast ptosis and visible lumpiness, especially in the lower pole of the breast.The breasts were surgically explored. The inferior semiperiareolar incision was chosen in order have direct access to the mammary gland and because of its minimal visibility. Macrolane was found in multiple pockets within the breast parenchyma. The lumps were singularly evacuated by infusing the tissues with saline and squeezing out the hyaluronic acid. A total of 20 lumps were emptied, 12 in the left breast, with one lump identified within the pectoralis major muscle, and eight in the right breast, with one lump found in the axillary cavity. The cysts were not excised in order to avoid reducing the breast volume and altering the breast parenchyma.1 With reference to breast augmentation, dual-plane placement of the prostheses was chosen in order to correct the breast ptosis and adequately cover the implant. Breast enhancement was performed using 345-cc, round, silicone-filled breast implants (Natrelle Inspira TRM; Allergan, Markham, Ontario, Canada). The postoperative course was uneventful. Six months later, the patient had obtained good aesthetic results (Fig. 2).Fig. 2: Postoperative view of the breasts showing correction of the breast ptosis as well as of the Macrolane cysts.Surgical evacuation of multiple hyaluronic acid cysts in association with a dual-plane augmentation mammaplasty was performed in a patient who presented complications after bilateral breast injections with Macrolane. Although similar reports are described in the medical literature,1,2 there are a few aspects that we would like to discuss. We agree with McCleave et al.1 that the breast implant should be positioned in a Macrolane-free pocket in order to avoid an increased risk of infection of the prosthesis. However, as the product is expected to reabsorb over 12 to 18 months,3 we suggest waiting at least 9 to 12 months after the last Macrolane infiltration before performing any surgical procedure, in order to evaluate the actual breast volume and choose the appropriate implant size. Bhat et al.2 described a case of subglandular breast augmentation following previous enhancement with Macrolane. However, since neither the quantity nor the time of reabsorption of Macrolane is predictable, breast size can decrease over time and fail to provide adequate coverage of the prosthetic devices.4 Moreover, the ptosis can worsen. In our opinion, implant position should always be totally or partially (dual-plane) submuscular. In summary, Macrolane injections for breast enhancement can cause, in certain patients, an alteration of mammary anatomic structures of which the surgeon should be aware so that these patients can be offered an optimal aesthetic result. DISCLOSURE The authors have no financial interest to declare in the products or devices mentioned in this article. Nefer Fallico, M.D. Department of Plastic and Reconstructive Surgery “Sapienza” University of Rome Rome, Italy Mario Faenza, M.D. Department of Plastic and Reconstructive Surgery University of Sassari Sassari, Italy Luca Andrea Dessy, M.D., Ph.D. Department of Plastic and Reconstructive Surgery “Sapienza” University of Rome Rome, Italy Manuela Pili, M.D. Department of Plastic and Reconstructive Surgery University of Sassari Sassari, Italy Emilio Trignano, M.D., Ph.D. Department of Plastic and Reconstructive Surgery “Sapienza” University of Rome Rome, Italy Department of Plastic and Reconstructive Surgery University of Sassari Sassari, Italy

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