Abstract
Rippling is a recognized aesthetic complication of prepectoral implant-based breast reconstruction, and thin mastectomy flaps markedly increase its risk. We report a 35-year-old physically active woman with recurrent bilateral fibroadenomas who underwent bilateral nipple-sparing subcutaneous mastectomy with immediate prepectoral implant reconstruction; the prepectoral plane was chosen to avoid animation deformity, weighed against her thin flaps. Visible rippling attributable to thin soft-tissue coverage developed at three months. Autologous fat grafting gave only partial, temporary correction. Four months later, a single staged, combined procedure achieved definitive correction: bilateral exchange to highly cohesive silicone gel implants, conversion to a subpectoral pocket, Wise-pattern mastopexy, and adjunctive lipofilling, with a right local inferior-pedicle rotation flap correcting a medial contour defect. At 12 months, rippling had resolved with a satisfactory aesthetic outcome. Thin flaps were considered the principal contributing factor, although a single case cannot establish causation. Because prepectoral reconstruction relies on the soft-tissue envelope for implant camouflage, thin flaps may favor considering primary subpectoral or dual-plane placement, or planned soft-tissue support such as acellular dermal matrix or autologous coverage. Salvage addresses the determinants of rippling in combination: fat grafting to thicken tissue, pocket conversion to add muscular coverage, mastopexy to tighten the skin envelope, and exchange for a more cohesive implant, although simultaneous performance precludes isolating any single component's contribution. Thin mastectomy flaps appear to be an important risk factor, potentially informing patient selection. Once rippling occurs, a staged multimodal approach can restore contour.