Classification of Breast Implant Malposition

Abstract

Background

Implant malposition is a well-recognized complication of prosthetic breast implants. However, to date, no objective classification system has been described.

Objectives

The aim of this study was to perform a prospective trial of an objective and reproducible classification system for implant malposition formulated by analyzing retrospective data from a large cohort of patients with implant malposition.

Methods

The authors retrospectively analyzed the degree of medial/lateral and inferior/superior implant malposition relative to their optimal position within the breast footprint in a series of 189 breasts (n = 100 patients). An objective classification system for implant malposition was devised and then applied to a prospective cohort of 53 breasts in 28 patients with implant malposition.

Results

The degree of malposition in a single or combination of axes was categorized according to the distance (measured in centimeters) from the ideal breast footprint. The classification system incorporated the axis of malposition and distance to generate a treatment decision-making guide. Cases of Grade 1 malposition did not warrant surgical intervention, whereas surgical correction was warranted in all Grade 3 cases. In the combined patient cohort (n = 242 breasts, 128 patients), lateral, inferior, medial, and superior displacement ranged between Grades 1 and 3. There was no interobserver variability in the grades assigned to 9 out of 10 patients in the prospective group.

Conclusions

A simple and reproducible classification system for implant malposition has been created that allows surgeons to objectively record the extent of malposition, guides surgical decision-making, and can be used to document the results of any intervention.

Level of Evidence: 3

Prosthetic breast implants are widely used in reconstructive and aesthetic breast surgery, with over 255,000 patients in the United States undergoing breast augmentation in 2022.¹ Depending on the indication and implant used, long-term core studies suggest that the rate of implant malposition in aesthetic and reconstructive breast surgery varies between 1% and 11.5%.^2-5 Smooth implants may have a higher rate of malposition than textured implants.^6,7

Implant malposition can manifest in a wide range of clinical presentations such as pseudoptosis,⁸ the high-riding nipple,^9,10 double-bubble deformity,¹¹ and bottoming out.¹² However, despite the publication of classification systems^9,13,14 and treatment algorithms^9,11 for these implant-associated deformities, interchangeable use of the terms to describe these complications has led to confusion over their exact definitions in the literature.

Examples of other simple and useful classification systems employed universally in breast plastic surgery include the Regnault classification of breast ptosis¹³ and the Baker classification of capsular contracture,¹⁵ both of which are used widely because they are useful, memorable, and easily applied to clinical practice.

The literature is replete with classification systems for ptosis, high-riding nipples, and pseudoptosis, but despite the continuing wide use of breast implants and the significant burden of postoperative implant malposition, at the time of writing there is no objective malposition classification system¹⁶ to aid analysis, professional communication, or surgical decision-making.

In this paper we propose a new, universally applicable classification system based on measurements that can easily be undertaken alongside a surgeon's usual preoperative planning. This study does not seek to dictate exactly which surgical approach is taken to address implant malposition; several excellent descriptions of techniques have already been detailed in the literature.^9,11,17-19 This study focuses specifically on the presentation of implant malposition, rather than the etiology, and as such, we have not included analysis of implant type, surface, or plane of pocket—these have been extensively published previously.^2-7,20-22

The goals of our classification are several-fold: (1) to provide a simple, useful, and pragmatic system for describing the degree of implant malposition (akin to the Baker¹⁵ classification of capsular contracture, or the Regnault¹³ classification of breast ptosis); (2) to guide potential decision-making regarding when to intervene surgically in cases of implant malposition; and (3) to aid discussion and communication between surgeon and patient, as well as colleague to colleague.

METHODS

The first part of our study involved a multicenter retrospective analysis of patients with unilateral or bilateral breast implant malposition after undergoing primary or secondary aesthetic breast procedures between November 2005 and September 2022 (17 years, 0 months). The charts of 465 revision breast implant patients (n = 930 breasts) were reviewed for potential inclusion into the study. Of these, 201 (43%) were assessed as having a degree of implant malposition. However, inclusion into the study required the availability of both comprehensive standardized clinical measurements and clinical photography. Cases with ptosis or pseudoptosis that obscured the inframammary fold (IMF) in frontal clinical photographs were excluded from further analysis because our proposed classification system required an assessment in relation to the IMF for caudal/inferior malposition.

The preoperative clinical photographs of the study group of patients were retrospectively calibrated by adapting the technique described by Eric Swanson.²³ Standardized preoperative frontal clinical photographs were taken with the same positioning and lighting using a Panasonic Lumix DC-G100 (Panasonic Holdings Corporation, Osaka, Japan) with a 42.5 mm compact lens at 2.5 meters, or a Nikon D5600 (Nikon Corporation, Tokyo, Japan) with a 18-55 mm lens at 1.5 meters. Standardized clinical measurements taken preoperatively, such as the sternal notch to nipple distance, were sourced from each patient's charts. The ruler tool in Adobe Photoshop 2018 (Adobe Systems, Inc., San Jose, CA) was then used to calculate the number of pixels between the 2 relevant measurement points (eg, sternal notch and nipple) on preoperative frontal photographs. A scale was then produced between the number of pixels between the 2 measurement points and the known patient-based measurement in centimeters. Once calibrated, the extent of implant malposition could be objectively calculated in 189 breasts (n = 100 patients) that demonstrated implant malposition.

The optimal position of the IMF in clinical photographs was determined according to Swanson's recommendation that 50% of the breast should sit above and below the position of the nipple-areola complex.^17,24 Any superior or inferior displacement from the ideal IMF was calculated using the ruler tool and the measurement in centimeters was recorded.

In the first part of the study medial displacement was calculated as the distance the medial edge of the implant extended medially beyond the ideal medial boundary. Lateral malposition was measured as the distance the medial aspect of the implant was lateralized from the ideal medial boundary.

Although not a substitute for direct clinical examination, the large number of implant malposition measurements in the retrospective analysis informed our decision-making when formulating the classification.

We also noted any surgical intervention that had been undertaken that was targeted at addressing implant malposition specifically. This was then correlated with the patient's degree of malposition and their subsequent grading in the malposition classification system that we developed.

Formulation of the Classification System

Based on our observations, we developed 3 grades of malposition severity and applied these to each axis of malposition (superior, inferior, medial, and lateral). These observations were subsequently corroborated in our prospective cohort of patients assessed in the second part of our study.

Displacement of less than 1 cm was classed as Grade 1, 1 to 3 cm of displacement was classed as Grade 2, and displacement of more than 3 cm was classed as Grade 3 (Figure 1A-E). The distances recorded were annotated according to the following system: S, superior displacement; I, inferior displacement; M, medial displacement; L, lateral displacement.

Each grade was accompanied with an abbreviation in brackets denoting whether the malposition was seen on the left (L) or right (R) breast. Correspondingly, a bilateral lateral implant displacement of 2 cm would be graded as:

“(L) L2; (R) L2”

In another example, a revisional breast augmentation patient presenting with 4 cm lateral and 2 cm inferior displacement of the left implant and 3.5 cm inferior and 2 cm lateral displacement of the right implant, would be summarized as follows:

(L) I2, L3; (R) I3, L2

Application of the Classification System

Having developed the classification system based on data from the retrospective cohort, it was applied to a prospective cohort of 53 breasts that demonstrated implant malposition (n = 28 patients) to ensure the reproducibility and validity of the system in clinical cases in the outpatient setting. These patients were being assessed for revisional aesthetic breast surgery between January 2021 and January 2024 (3 years, 0 months) after presenting with unilateral or bilateral breast implant malposition following primary or secondary aesthetic breast procedures. After being assessed by one of the senior authors using the classification system, 10 successive patients in the prospective cohort (n = 18 breasts) were also independently assessed by a senior surgical resident or experienced aesthetic plastic surgery nurse using the same technique to investigate any interobserver variability that may occur—interobserver variation being a crucial aspect in determining the application and usefulness of any clinical assessment tool.

In the prospective cohort, breast footprints (as outlined by their implants or natural breast boarders) and ideal breast aesthetic lines (determined by displacement of the breast and/or implant) were marked preoperatively while patients were standing (Figure 2A, B).

Superior (cranial) malposition was assessed relative to the natural upper borders of the breast (as defined by a combination of the axillary fat pad, the second rib, and the cranial commencement of any striae present) (Figure 3).

Inferior (caudal) malposition was assessed by comparing the position of the present IMF with the ideal IMF position as assessed by the examiner by cranial displacement of the implant. Importantly, the position of any IMF scar was ignored due to the possibility that this might have not been placed in the optimal position when planning the original surgery.

Medial displacement (that might result in symmastia) was determined by the examiner pushing the implant laterally to its optimum position with the patient standing. The distance between the ideal medial boundary of the implant and the point at which the medial edge of the implant was initially sitting was then recorded, thus measuring the distance that the initial medial boundary of the implant extended beyond the ideal medial line.

In the outpatient setting, instead of measuring lateral malposition from the ideal medial boundary as described in the retrospective analysis, the senior authors found it more logical to mark the position of the lateral curvature of the breast or implant and then medialize the implant to its ideal position. The difference between the initial and ideal position of the lateral boundary of the breast or implant could then simply be measured (Figures 2A, B and 4A, B; Video).

We chose not to include negative numbers in the classification system in cases where the implant did not reach the desired border because this is not typically referred to as implant malposition and we felt it would overcomplicate the system.

Although we considered assessing lateral malposition with the patient supine as well as standing, lying the patient supine often overemphasized lateral displacement beyond what was seen during the majority of the patient's daily activities. Therefore, lateral displacement was assessed only whilst patients were standing, using manual pressure to displace the implant medially within its pocket for marking. It was noted that with the patient supine, the implant sometimes extended beyond the marking to a variable amount, often related to the shape of the chest wall and size and weight of the implant.

A database was established to record patient demographics, surgical procedures, indications for surgery, and malposition grades for both the prospective and retrospective cohorts (Supplemental Tables 1, 2). All patients were followed up for a mean of 10.26 months (range, 1-12 months). This study follows the principles of the Declaration of Helsinki and all patients whose clinical photographs feature in this paper provided written informed consent.

RESULTS

Our classification system was developed by analyzing retrospective data from preoperative clinical photographs of 100 patients (189 breasts; age range, 19-76 years; mean, 46 years) with implant malposition who were undergoing revisional aesthetic breast procedures. The classification was then prospectively applied to 28 patients (53 breasts; age range, 20-67 years; mean, 42 years) being assessed for revisional aesthetic breast surgery to demonstrate the validity of the system and its reproducibility in clinical practice.

Three patients in the prospective cohort demonstrated unilateral implant malposition (left implant, n = 1; right implant, n = 2) and 25 patients had bilateral implant malposition. In the retrospective analysis, 11 patients exhibited unilateral malposition (left implant, n = 4; right implant, n = 7) and 89 patients were seen to have bilateral implant malposition.

In the prospective analysis, patients presented for revisional surgery due to malposition (n = 12), their own choice (n = 8), and capsular contracture (n = 2). In the retrospective cohort, patients presented for further revisional procedures due to their own choice (n = 38), capsular contracture (n = 14), implant rupture (n = 11), and malposition (n = 11).

Four patients in the prospective cohort underwent implant exchange and mastopexy (n = 8 breasts), 4 patients underwent implant exchange and capsulectomy (n = 8 breasts), and 4 patients underwent implant exchange, capsulectomy, and mastopexy (n = 8 breasts). In the prospective group, 2 patients are being monitored for the need for revisional surgery and 1 patient had not yet undergone implant exchange and mastopexy by the time this study was undertaken. In the retrospective group, 33 patients underwent implant exchange and mastopexy (n = 66 breasts), 32 patients underwent implant exchange and capsulectomy (n = 58 breasts), and 14 patients underwent implant exchange after capsulotomy alone (n = 28 breasts).

When the malposition grades in the prospective and retrospective groups were combined (total, 242 breasts), 79.8% of breasts displayed inferior malposition (n = 193), 76.0% of breasts demonstrated lateral malposition (n = 184), and 61.6% of breasts had a degree of inferolateral displacement (n = 149). A further 5.4% of breasts were seen to have medial malposition (n = 13) and 5.0% of breasts superior malposition (n = 12), ie, high-riding implants. A visual summary of the distribution of malposition grades can be found in Figure 5.

Of breasts with inferior malposition (n = 193), 5.18% were Grade 1 (n = 10), 62.2% were Grade 2 (n = 120), and 32.6% were Grade 3 (n = 63). Of breasts with lateral malposition (n = 184), 6.5% were Grade 1 (n = 12), 77.7% were Grade 2 (n = 143), and 15.8% were Grade 3 (n = 29).

Malposition measurements taken by the senior surgical resident and the experienced aesthetic surgery nurse differed by less than 1 cm compared with those taken by the senior authors in 9 out of 10 patients (n = 16 of 18 breasts) included in the interobserver variability part of this study. All of these 9 patients were assigned the same grade by the senior resident and the senior author. In 1 patient (n = 2 breasts) the surgical trainee assigned a grade of “(L) S1, (R) S1,” whilst one of the senior authors assessed the patient to have “(L) S2, (R) S2” malposition. This high degree of concordance was deemed to validate the future application of our classification system.

Patients were followed up with face-to-face reviews for 1 to 12 months after revision surgery in the prospective cohort (mean, 6.14 months) and for 6 to 12 months in the retrospective group (mean, 11.42 months). Patients included in this article were not recalled specifically for the purpose of this study, and therefore the length of follow-up was determined by their routine appointments (which were always offered for at least 1 year after surgery). Further details of the patient demographics, surgical procedures, indications for surgery, and malposition grades can be found in Supplemental Tables 1 and 2.

Correlation of Malposition Grade and Surgery

When reviewing patients (and individual breasts) in both groups and analyzing whether further surgery to address the malposition was undertaken, specific patterns became apparent.

Indications for surgery were rarely due to a single concern, with many patients choosing to proceed with surgery due to several implant- and tissue-related factors²⁵ alongside malposition, such as requests to change implant volume, concerns regarding breast feel, lack of upper pole fullness, and cases in which long-standing implants were being changed at the patient's request. However, all patients who were classified as having a Grade 3 malposition underwent revisional surgery with the intention of addressing the malposition as a specific indication. Conversely, none of the Grade 1 malpositioned patients underwent surgery to address their malposition alone, and indeed malposition was never the primary indication for revision surgery in Group 1. The patient shown in Figure 6 is a good example of a good overall aesthetic outcome from breast augmentation surgery, despite a Grade 1 “(R) I1” malposition (Figure 6A-D). She was unaware of the relatively minor degree of inferior malposition and was satisfied with her outcome. This typical presentation of Grade 1 patients led us to recommend that surgery to address malposition in a Grade 1 patient with no other surgical indications is not undertaken.

In the Grade 2 patients, there was a variation in decision-making, which was tailored to the patients’ goals and the surgeon's professional recommendation. Malposition was a variable factor in the decision-making for Grade 2 patients to undergo revision surgery.

As such we can make the following recommendation in applying our classification system:

• Grade 1: No surgical intervention indicated to address malposition.

• Grade 2: Decision to surgically address implant malposition dependent on outcome of surgical assessment and patient goals.

• Grade 3: Surgical intervention warranted to address malposition.

DISCUSSION

In this paper we propose a simple, objective, universally applicable implant malposition classification system, based on measurements that can easily be undertaken alongside a surgeon's usual preoperative planning. This classification system has practical applications in clinical decision-making as well as being useful for documentation and communication purposes.

Prosthetic breast implants are still widely used in reconstructive and aesthetic breast surgery across the globe.^1,26 The wide range of malposition rates provided by core studies^2-5 reflects the variety of factors that can influence implant displacement, including the size and type of prosthesis,⁷ implant pocket,²⁰ patient characteristics,²¹ plane of surgical dissection,²² and indication for surgery.^3-5 Although there is evidence that suggests that smooth implants have significantly higher malposition rates than other textured prostheses, the presence of other confounding factors make it difficult to generalize the results beyond the implants examined in each paper.^6,7 We intentionally did not include analysis of implant surface type in this paper because it was deemed outside the specific aims of the study.

In response to the significant burden of implant malposition, a variety of capsulorrhapy,^19,27,28 capsulectomy,²⁹ and internal suturing techniques³⁰ have been described to reshape and reposition the implant pocket. Some authors also advocate moving the implant to a new plane^31,32 or providing extra support for prostheses using capsular flaps^18,33 or acellular dermal matrix.³⁴ Most recently, the use of external sutures to provide increased stability to the revised breast footprint and skin tailoring over the implant pocket has also been documented.³⁵ However, because each of these techniques are used alongside a variety of implant types, placed in a number of anatomical planes, for a range of surgical indications, it is still not clear if any of these techniques achieve superior results, and therefore the approach taken by each surgeon needs to be tailored to the individual patient, with techniques that work best in the surgeon's own hands. We are not advocating a particular surgical solution for implant malposition in this study.

Any classification system needs to be pragmatic, simple, and reproducible to be of use in clinical practice.^36,37 Our classification fulfils all the above criteria; however, we do not dictate the method of surgical intervention as this needs to be decided on by the surgeon according to their experience, familiarity with technique, and individual patient presentation. We also propose that our classification system could be usefully applied to monitoring breast implant patients prospectively over time.

The development of our malposition classification system was a natural progression from the usual preoperative marking of patients undergoing revisional aesthetic breast surgery in our practices. We advocate marking the patient's preoperative breast footprint and ideal breast lines when standing (Figure 2A, B; Video). Any superior or inferior displacement from the ideal IMF, or medial or lateral displacement from the ideal medial/lateral breast border, can then be measured in centimeters, marked, and recorded in clinical photographs for future reference.

To objectively measure implant malposition, one has to have an appreciation for the “ideal” breast footprint. Although multiple papers have outlined the components of ideal breast aesthetics,²⁴ the increased use of patient-reported outcomes in aesthetic breast surgery³⁸ re-emphasizes that the “normal breast” footprint is intuitively recognizable³⁹ and can be formally evaluated by patients themselves.

In plastic surgery, the benefits to interprofessional communication, data collection, and treatment planning afforded by the use of well-established classification systems^13,15 vastly outweighs the criticism they have received.^17,40

At the time of writing, the authors are only aware of the malposition classification system described by Guarin et al in 2021.¹⁶ Lateral displacement is categorized into 2 groups depending on whether the implant extends beyond the anterior axillary line or not. Medial displacement is differentiated into unilateral medial displacement that does not extend beyond the midline and bilateral medial displacement that extends beyond the midline. Superior and inferior malposition are defined when an implant is displaced superior to the interaxillary line and inferior to the IMF, respectively. All patients with displacement in 2 or more planes are grouped into a final fifth category.

Despite the simplicity of this proposal, the relation of implant displacement to anatomical landmarks without any discrete measurement reduces the objectivity and applicability of the system. The combination of measurements that define our classification provides an objective analysis of multiplane implant malposition that can be succinctly communicated to colleagues.

Any implant malposition classification system should acknowledge that the IMF scar may not be the most appropriate landmark for assessing inferior displacement because it may not correspond to the ideal IMF position in patients who have undergone previous aesthetic breast surgery.⁴¹ A measurement between the IMF scar and ideal IMF was not included in our classification system because the IMF scar may have been incorrectly placed at the original surgery. However, it is still important to note the relationship of the scar to the ideal IMF position due to its relevance in revisional surgery, particularly when incorrect placement of the IMF scar causes “double bubble” deformity.

We acknowledge that both our system and the proposal from Guarin et al rely on definite anatomical boarders of the breast which are not universally accepted.^17,24,41

We tested our initial hypothesis of a potential classification system by examining a large retrospective cohort of calibrated patient clinical photographs, as this has previously been used successfully to assess postoperative breast measurement changes⁴² and normative breast aesthetic data,³⁹ and to devise other classifications within breast surgery⁴³. Therefore, we felt this method offered a pragmatic way to assess and develop our classification system, which was then confirmed in the clinical setting.

We acknowledge that the method of measuring lateral malposition necessarily varied between the retrospective and prospective cohorts. The standardized clinical measurements that calibrated our clinical photographs (eg, nipple to notch) could only be accurately marked on frontal clinical photographs. As a result, lateral malposition had to be assessed from the ideal medial boundary, as the lateral boundary of the breast or implant was not always visible on frontal photography. However, the 2 senior authors found that measuring lateral malposition from the lateral breast boundary was more logical and memorable when applying the classification in clinical practice, and therefore this method was incorporated into the final system.

We recognize that lateral malposition could be measured either when the patient is supine or when standing. Indeed, the authors debated the pros and cons of each option at length. When supine, lateral implant malposition is exacerbated and often this is the position that patients will adopt to demonstrate their concerns. However, we felt that when supine, often the degree of lateral malposition is somewhat overemphasized, and indeed, the intraoperative findings are frequently that the extent of the pocket enlargement laterally is not as great as predicted; it is the weight of the implant that further lateralized the position of the breast. Therefore, although there is no “correct” answer to the “best” position to measure this axis of malposition, in view of the fact that the other measurements were being undertaken with the patient standing, and the breast/implant could be lateralized by manual displacement when standing to determine the degree of pocket/implant lateral malposition, we chose to use only standing assessment for lateral malposition. Finally, and perhaps somewhat nuanced, it is often less the degree of lateral malposition when supine that patients complain of, but rather the degree of medial breast emptiness that is secondary to the lateralization of the implant.

We maintain that the development of the classification system is an iterative process informed (but not solely dictated) by data from the retrospective analysis and then adapted after the prospective trial to ensure that the system is practical and reproducible in clinical practice. As a result, we think that the slight discrepancy in the methodology between the retrospective and prospective group is an acceptable part of the process of developing and applying a new classification system.

We note that simple classification systems, that can be read once and readily applied, often have a larger impact on clinical practice as they are memorable and practical, and therefore consistently used by a wide variety of clinicians over a longer period of time. Accordingly, although “Cranial” (Cr) and “Caudal” (Ca) were our initial preferred terms for malposition in the coronal plane, the abbreviations for these descriptors were easily confused and so we opted for the clearer “Superior” (S) and “Inferior” (I) nomenclature that is seen in our system.

There are a variety of potential contributory factors to implant malposition, some of which may be iatrogenic (eg, inappropriate pocket dissection, poor choice of scar position), whereas others might be anatomical (eg, chest wall asymmetry). It is possible that the morphology of the chest wall can occasionally give rise to an “illusion” of implant malposition, when in fact the implant is sitting as intended or required in the particular situation. We recognize that in these occasional settings, it might be inappropriate to use our classification system for assessment; however, we foresee that in the vast majority of cases our system can be applied.

As with all pragmatic and clinically applicable classification systems, clinical documentation does not solely rely on the single noting of the grade or stage observed, but is also accompanied by relevant and helpful descriptive observations. Examples that are used in daily practice include Regnault's classification of breast ptosis¹³ and Baker's classification of capsular contracture.¹⁵ However, what these systems, and ours, have in common is that the clinician is immediately able to understand and form a global picture of the clinical situation on hearing the relevant grade assigned.

Although implant malposition could be viewed as an indication for optional elective revision surgery in contrast to the need for surgery mandated by the pain associated with Grade 3 or 4 capsular contracture, the number of breast surgery patients in our study and the wider literature^25,44 who present for revisional surgery due to concerns about malposition suggests that implant displacement frequently motivates patients to present to clinicians for surgical correction. Anecdotally, this is particularly an issue for lateral malposition that patients typically complain of when lying down, and inferior malposition that is evident when they remove their bra.

We acknowledge the difficulty in creating classification systems that can be reliably used across clinical practice, especially when the impact of interobserver variability may result in a patient being assigned different malposition grades by different clinicians using our method (something that is evident with the use of the Baker classification system of capsular contracture). However, malposition measurements taken by our senior authors and their senior resident/senior aesthetic plastic surgery nurse differed by less than 1 cm in 9 out of 10 prospective patients. The high correlation between assessors provides evidence that our system can produce accurate and reliable malposition measurements that are unlikely to lead to significant interobserver variability when the classification is applied across different clinical settings by surgeons with varying levels of experience. In using the classification system in widespread clinical practice, inevitably there might be some disagreement over “borderline” cases—similar to the use of the Baker classification system of capsular contracture.⁴⁰ However, due to the simple and reproducible nature of the classification system we propose, we do not envisage this being a key future issue.

Inferior, lateral, or inferolateral displacement was exhibited by 82% (n = 23) of the prospective group and 98% (n = 98) of the retrospective cohort, which corroborates the high prevalence of inferior and/or lateral malposition seen in previous studies.⁴⁵

The retrospective cohort in this paper was sourced from a larger group of revisional breast surgery patients (n = 465 patients, 930 breasts) in the practices of the senior authors. In total, 201 (43%) of these patients were subjectively assessed to have implant malposition; however, standardized clinical measurements for objective retrospective analysis were found for only 100 of these patients. We acknowledge that our inclusion and exclusion criteria limited the retrospective analysis to a smaller subgroup of the original cohort, but maintain that these strict parameters ensured that the retrospective photographic analysis was robust, which in turn reaffirmed the validity of the classification system.

Both senior authors of this study have large breast implant revision practices, which might explain the high proportion of patients encountered with implant malposition. However, it is also important to note that 17% (n = 17) of the patients in our retrospective group exhibited Grade 1 displacement in at least 1 plane. The difficulty in differentiating Grade 1 malposition from normal limits leads us to recommend that Grade 1 malposition is within an acceptable range with no indication for surgical intervention on this basis alone, and that only Grades 2 and 3 should be considered “pathological,” analogous to the Baker grading system of capsular contracture.¹⁵ Even in Grade 2 malposition, the indication for surgery can be debated, and our recommendation is that Grade 2 cases are approached on a case-by-case basis, with review by the surgeon and discussion with patient about the potential advantages and disadvantages of revisional surgery. Grade 3 malposition cases, in our view, warrant surgical intervention, which is a view supported by the fact that all Grade 3 cases in this study underwent corrective surgery for malposition.

Since implementing the classification system into the practices of the senior authors (P.A.H. and M.D.P.), the following have been observed: (1) clearer discussions with our patients about whether or not intervening surgically in cases of implant malposition is warranted—it helps patients if they understand “objectively” that their malposition may be Grade 1, ie, mild, for example; (2) the system has allowed us to document our observations in our patient charts, alongside our observations of Baker classification and other key factors that help put the patient's clinical picture together; (3) when we discuss our patients with one another (which the senior authors do frequently), using the classification system in our conversation enables the other colleague to instantly get a picture of the patient's clinical situation; and (4) we have found that conversations about surgery in patients with Grade 2 malposition are more nuanced and individualized and less “cookie cutter” and algorithmic.

CONCLUSIONS

We have created a universally applicable, simple, and reproducible classification system for implant malposition based on easily obtained measurements. The classification system can aid surgical decision-making and documentation, becoming easily incorporated into the preoperative planning processes. We also propose that the system is used in routine postoperative follow-up documentation as part of patient monitoring. Whilst we have developed the system in aesthetic breast cases, it could also be applied to implant-based breast reconstruction cases and as a framework in future studies to objectively assess specific surgical techniques used to address implant malposition.

Supplemental Material

This article contains supplemental material located online at www.aestheticsurgeryjournal.com.

Acknowledgments

The authors would like to thank Ms Julia Ruston for producing the medical illustrations in the paper.

Disclosures

Dr Pacifico undertakes paid educational work for Mentor (Mentor Worldwide LLC, Irvine, CA) and Johnson & Johnson (New Brunswick, NJ). Otherwise, the authors do not have any institutional or corporate affiliations, have not received funding for their academic work in the past 36 months, and do not have any other topically related relationships.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

REFERENCES

Author notes