Augmentation Mastopexy

Augmentation mastopexy using the "double inner bra technique" (DIB) in post-bariatric surgery

BACKGROUND

Augmentation mastopexy has a 20-fold higher complication rate than primary augmentation. Performing augmentation mastopexy in post-bariatric patients poses an additional challenge owing to the reduced quality of the soft skin tissue. Therefore, it is technically complex and also fraught with complications. Implant dislocation, recurrent ptosis, wound healing problems with exposed implants, and the threat of implant loss are complications that must be prevented.

METHODS

We present a case series study on our technique for stabilizing breast implants using the double inner bra technique (DIB) in which a laterobasal myofascial flap and an inferiorly based dermoglandular flap form a double inner bra for implant stabilization and protection.

RESULTS

Thirty-seven cases were operated on using this technique from December 2020 to June 2023. No hematomas (0%), seromas (0%), infections (0%), and implant losses (0%) were recorded. Moreover, none of the patients had implant malposition (0%). With regard to recurrent ptosis mammae or waterfall deformity, 7 cases (2.6%) showed early ptosis within the first 3 months, and the number of ptosis decreased over time. Furthermore, 5 (1.81%) patients showed ptosis mammae after 6-12 months. Implant defect or rupture has not yet occurred (0%).

CONCLUSION

The DIB is an easy-to-learn and versatile technique. It has low complication rates and can be used to achieve esthetically satisfactory mid- to long-term results.

Safe Augmentation Mastopexy: Review of 500 Consecutive Cases Using a Vertical Approach and Muscular Sling

Background

Augmentation mastopexy remains a challenging surgery and has been frequently associated with suboptimal outcomes and remarkable reoperation rates, and one of the greatest challenges in mastopexy surgery is areolar lift, especially when implants are simultaneously used. Through the authors' experience, this study is aimed to show a modification of the vertical approach with greater safety of the areolar pedicle.

Methods

The study included all patients who underwent augmentation mastopexy surgery performed by the authors between 2019 and 2022, whether primary or nonprimary, and performed a retrospective chart review of all patients who underwent this procedure.

Results

The length of the areolar lift ranged from 0 cm to 14 cm. Among the 17.4% of nonprimary mastopexies, the longest areolar lift was 11 cm. No cases of nipple-areola complex ischemia/necrosis were observed. With this technique, there were 6.2% complications (n = 31), none of which were considered serious.

Conclusions

This surgical sequence is a safe option for areolar lift in augmentation mastopexy. The vertical approach also has the advantage of producing considerably shorter horizontal scars. It is also reproducible, keeping the implant stable, which results in consistent long-term results.

Correlation between Capsular Contracture Rates and Access Incision Location in Vertical Augmentation Mastopexy

BACKGROUND

Plastic surgeons commonly use one of three access incisions to place breast implants during vertical augmentation mastopexy, including inframammary, vertical, and periareolar. It is not known whether there is a correlation between capsular contracture and access incision location. The purpose of this study was to investigate in a single-surgeon series the incidence of capsular contracture associated with access incision locations in silicone vertical augmentation mastopexy.

METHODS

Patients undergoing a vertical augmentation mastopexy between 2013 and 2017 were studied retrospectively. All patients underwent a standardized, dual-plane breast augmentation with smooth surface silicone gel implants. Patients were evaluated 1 year postoperatively by the Baker scale.

RESULTS

A total of 322 patients met study criteria. Eighty-four had periareolar access, 86 had vertical access, and 152 had inframammary access. There were no differences in patient age or mean implant size between the groups. The capsular contracture rate of the periareolar group was 5.36 percent; in the vertical access group, 3.48 percent; and in the inframammary access group, 1.64 percent. Capsular contracture rates correlated inversely to the distance to the nipple-areola complex, with the periareolar access rates the highest, the vertical access rates intermediate, and the inframammary access rates the lowest. Inframammary incisions were associated with lower capsular contracture rates than periareolar incisions when performed in conjunction with vertical augmentation mastopexy ( p = 0.043). Vertical access capsular contracture rates were intermediate between periareolar and inframammary groups.

CONCLUSION

Surgeons should take into consideration the capsular contracture rates associated with access incision location when planning or performing vertical augmentation mastopexy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Reoperative Augmentation Mammoplasty: An Algorithm to Optimize Soft-Tissue Support, Pocket Control, and Smooth Implant Stability with Composite Reverse Inferior Muscle Sling (CRIMS) and its Technical Variations

BACKGROUND

Reoperative augmentation mammoplasty (RAM) is a challenging procedure, with the highest rates of complications and revision. Complications include implant malposition, lateral displacement, bottoming out, and rotation. These deformities can be addressed with various procedures, but the pocket control and stability of the new smooth implant surface may present limitations.

OBJECTIVES

This study revisits a previously described predictable approach in primary breast augmentation and defines a surgical treatment algorithm for RAM technique selection.

METHODS

Between 2017 and 2021, 72 patients (144 breasts) underwent RAM with composite reverse inferior muscle sling (CRIMS) technique and its technical variations (types I-IV). CRIMS technique involves placing a silicone gel implant into the submuscular (SM) pocket with an inferior sling of the pectoralis major muscle based on the dimensions of the implant, in combination with support points/dermal bridge sutures to stabilize the implant and glandular tissue at the lower breast pole (LBP). Reasons for surgery were ptosis (92%), implant and malposition (59.6%). Patients were followed for at least 6 months in 5 cases (6.9%), at least 12 months in 50 cases (69.4%), for at least 36 months in 10 cases (13.8%), and more than 36 months in 7 cases (9.7%) (mean 34 months; range 6-48 months). Patients were evaluated in terms of resolution of symptoms, satisfaction, and complications. Three-dimensional imaging (3DI) obtained from the Divina scanner system was used and followed up for 1 year to evaluate breast position, lower pole stretch (LPS), and intermammary distance (IMD).

RESULTS

Eleven cases of minor complications were observed in 9 patients (12.5%): hypertrophic scarring in 4 (5.5%), wound dehiscence in 4 (5.5%), Baker II/III capsular contracture in 1 (1.3%). SmoothSilk surface silicone implants were used in all cases, with an average volume decrease of 120 cc. Sixty-eight patients (94.4%) were either very satisfied/satisfied with their aesthetic result. Breast images were performed in a group of 65 patients (90.2%), and in 7 breasts (10.7%), localized oil cysts were observed. The value for LPS was 7.87% (p <0.0001) between 10 days and 1 year, with the majority occurring early in the first 3 months, indicating that the LBP/implant remains steady during the last months of follow-up. No cases of fat necrosis/seroma were observed. There were no signs of intra/extracapsular ruptures, capsular contracture. There were 2 cases (3%) of minimal implant displacement and no cases of rotation.

CONCLUSIONS

CRIMS and its variations can be performed successfully in RAM. An algorithmic approach can facilitate the pre- and intraoperative decision-making process and provide the new pocket control and implant stability with acceptable complication rates. Further accurate evaluation is recommended to understand the benefits or disadvantages of CRIMS compared to other RAM techniques.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Finesse in Mastopexy and Augmentation Mastopexy

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe surgical techniques associated with mastopexy and mastopexy augmentation. 2. Understand the evolution of mastopexy and augmentation mastopexy. 3. Address patient goals. 4. Achieve a favorable cosmetic outcome.

SUMMARY

The surgical techniques associated with mastopexy and mastopexy augmentation have continued to evolve. Traditional mastopexy techniques have included periareolar, circumvertical, and inverted-T patterns; however, adjuncts to these have included the use of various surgical mesh materials, implants, and fat grafting. This evidence-based article reviews how the techniques of mastopexy and augmentation mastopexy have evolved to best address patient goals and provide a favorable cosmetic outcome.

Hybrid mastopexy: improving outcomes on implant-based augmentation mastopexy with fat

Background

Autologous fat transplantation for breast augmentation represents an increasingly interesting technique in plastic surgery. Only a few standardized procedures are available. Hybrid augmentation mastopexy combines the benefits of autologous fat transplantation and implant-based breast augmentation mastopexy, reducing implant-related complications and prothesis size. Herein, we describe our surgical approach as a “hybrid aesthetic surgery.”

Methods

A retrospective analysis of all patients who underwent hybrid breast augmentation and lifting with simultaneous fat grafting was carried out. Clinical outcomes, ultrasound evaluation of upper pole fullness, aesthetic postoperative results, and complications were examined.

Results

Eighteen patients with a mean age of 33 years (range: 24–52 years) and mean BMI of 25.8 kg/m2 (range: 21.4–32.1 kg/m2) were included in this study. Mean injected fat volume per breast was 115 cc (range: 78–144 cc). Patients were followed up for a mean of 9.4 months (range: 6–24 months). No fat necrosis or major complications were encountered during the follow-up. Patient satisfaction was high in terms of breast shape, size, and coverage of the breast implant. No recurrence of ptosis was observed yet and no secondary revision surgery was performed.

Conclusions

Hybrid mastopexy augmentation is an effective and safe procedure that combines the benefits of autologous fat grafting and implant-based breast augmentation. The transfer of autologous soft tissue allows obtaining a natural breast shape, reducing the onset of rippling and prothesis size. The reduction of prothesis size prevents ptosis recurrence but provides the desired projection. This reliable option improves long-term breast shape with elevated patient’s satisfaction.

Level of evidence: Level IV, therapeutic study.

Management of Granulomatous Mastitis Following Aesthetic Breast Surgery

BACKGROUND

Granulomatous mastitis (GM) is not among the well-known diseases in the field of aesthetic breast surgery (ABS). The clinical presentation of GM resembles infectious diseases or malignancies, but the management of these diseases is quite different. In this study, we aimed to present the management of GM in patients who underwent ABS.

METHODS

In this study, patients with GM (n = 65) and patients who underwent ABS (n = 531) were evaluated. A total of six GM patients with a history of ABS were included in the study between January 1, 2010, and January 1, 2019. The data were collected retrospectively. The quantitative variables are shown as medians (minimum-maximum), and categorical variables are shown as numbers and percentages (%).

RESULTS

Median duration of disease onset after the ABS was 16 (8-38) months. After the diagnosis of GM was obtained, all patients received steroid treatment. Median steroid treatment duration was 10 (8-20) weeks. Methotrexate was administered in two patients due to persistent breast mass and steroid side effect. Surgical excision was performed in three patients with wide excision. No patient needed further surgery such as mastectomy. Median follow-up period was 37.5 (18-70) months.

CONCLUSION

This is the first study to declare GM in patients who underwent ABS. Atypical clinical presentation such as breast abscess, mass or fistula after ABS should alert the surgeon about GM. Unlike other mastitis, the primary treatment of this rare disease is steroid and immunosuppressive treatment. Insufficient knowledge about GM can lead to unnecessary surgeries or breast loss.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Comparison of 28 Published Augmentation/Mastopexy Techniques Using Photographic Measurements

Background

Numerous augmentation/mastopexy methods have been described in the literature, including those reported in 16 publications in 2019. However, objective measurements of breast dimensions are lacking, leaving little information on which to base treatment selection. The goal is to increase upper pole projection using an implant and correct ptosis by elevating the lower pole with the mastopexy.

Methods

A PubMed search was conducted to identify published augmentation/mastopexy methods. Lateral photographs were matched for size and orientation and then compared using a 2-dimensional measurement system. Measurements were compared for 5 common approaches-vertical; periareolar; inverted-T, central mound; inverted-T, superior pedicle; and inverted-T, inferior pedicle. Four publications not fitting these 5 groups were also evaluated. Measurement parameters included breast projection, upper pole projection, lower pole level, breast mound elevation, nipple level, area, and breast parenchymal ratio.

Results

A total of 106 publications were identified; 32 publications included lateral photographs suitable for comparison. Twenty-eight publications fitting 1 of the 5 groups were compared. All published augmentation/mastopexy methods increased breast projection and upper pole projection, although not significantly for inverted-T methods. Vertical augmentation/mastopexy was the only method that significantly raised the lower pole level (P < 0.05). The vertical technique also significantly (P < 0.01) increased the breast parenchymal ratio. Periareolar; inverted-T, central mound; and inverted-T, inferior pedicle methods produced nonsignificant increments in the breast parenchymal ratio.

Conclusions

Breast implants increase breast projection and upper pole projection. Only vertical augmentation/mastopexy significantly elevates the lower pole. This method also significantly increases the breast parenchymal ratio, achieving the surgical objectives.

Augmentation Mastopexy:: Planning and Performance for Predictability: Management of Complications

Augmentation mastopexy is generally considered to be one of the most difficult operations in breast surgery. It has an undeserved reputation for high complication rates and unhappy patients. Through careful planning, surgical techniques involving manipulation of the breast while maintaining blood supply and implant cover, and good augmentation technique, the operation can achieve predictable results in most cases with a low complication rate. Techniques to assess and manage the 2 main complications of waterfall deformity and bottoming out are discussed.

Short-Scar Augmentation Mastopexy in Massive-Weight Loss Patients: Four-Step Surgical Principles for Reliable and Reproducible Results

BACKGROUND

Single-stage augmentation mastopexy is considered a challenging procedure, and its safety and efficacy remain controversial for breasts with grade-2 and grade-3 ptosis. In this paper, we report our experience in single-stage augmentation mastopexy with implants, using a short-scar technique, outlining the four-step principles of our technique which maximizes the cosmetic outcomes though being safe, reliable and reproducible.

PATIENTS AND METHODS

Forty consecutive massive-weight loss (MWL) patients undergoing short-scar augmentation mastopexy with implants between September 2010 and August 2018 were retrospectively analysed. The preoperative evaluation and our four-step surgical principles are presented in detail. Breast shape analysis was performed separately by a blinded group of plastic surgeons and by the attending surgeon using a standardized evaluation method. Breast-Q was used to evaluate patients' satisfaction.

RESULTS

Patients' average age was 43 (range from 29 to 54). Among the 40 patients, 2 patients were rated as grade 1 (5%), 21 cases (52.5%) grade 2 and 17 (42.5%) grade 3 according to Pittsburgh Rating Scale. The average follow-up time was 40 months (ranging from 3 to 96 months). No major postoperative complications were experienced. Patients' satisfaction was high to very high.

CONCLUSIONS

Augmentation mastopexy with implant in the MWL population remains a challenging procedure, especially in Pittsburgh grade-3 breasts. A bilamellar approach using proper footprint reconstruction allows for very satisfying cosmetic results using the short-scar mastopexy pattern with a very low complication rate. Our four-step surgical principles are provided, which may aid in the surgical planning and execution of such demanding cases.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Vertical Augmentation Mastopexy with Implant Isolation and Tension Management

Supplemental Digital Content is available in the text.

Background:

The increasingly popular vertical method of mastopexy is less commonly the technique of choice in augmentation mastopexy possibly due to concerns raised in the literature. The purpose of this report is to evaluate safety and satisfaction of the author’s variation of the vertical method in this combination surgery. It includes unique tension management steps and total implant isolation from cut parenchyma.

Methods:

A retrospective analysis was done of 105 consecutive patients treated with the author’s method over an 8 year 6 month period. Clinical outcomes were examined, and a Breast-Q survey and Spear’s 2004 survey were mailed to all patients who agreed to it by phone.

Results:

There were no hematomas or delayed healing but one pulmonary embolus treated as an outpatient and one infection appearing 6 weeks postoperatively. There were only 3 grade 3 or 4 capsular contractures. Sixty-seven patients consented to the survey and 36 were returned. With Breast-Q, there was a mean score of 82.78 for outcome satisfaction and 75.94 for satisfaction with breasts. Spear’s survey confirmed high satisfaction with 90.9% indicating that they were satisfied or extremely satisfied. Comparison with Spear’s own surgical results did not reach statistical significance.

Conclusions:

The author’s specific adaptation of vertical augmentation mastopexy appears to be very safe and successfully addresses a variety of healing, tension, and exposure concerns mentioned in the literature. Implant isolation may decrease capsular contracture rate. Both Breast-Q survey and Spear’s more specific survey indicate high patient satisfaction.

Can It Be Safe and Aesthetic? An Eight-year Retrospective Review of Mastopexy with Concurrent Breast Augmentation

Supplemental Digital Content is available in the text.

Background:

The safety of concurrently performing mastopexy and breast augmentation is controversial, due to the risk of breast tissue and nipple neurovascular compromise and overall potential high complications rates. This article describes a concurrent procedure of augmentation with implants and a “Tailor-Tack” mastopexy that consistently achieves an aesthetically pleasing breast with acceptable complication rates.

Methods:

This is a retrospective chart review of all consecutive breast augmentations performed concurrently with mastopexy using the “Tailor-Tack” technique by the 2 senior authors (M.M. and O.T.) over an 8-year period. Independent variables were patient demographics, surgical approach, implant type, shape, size, duration of follow-up, and complications. Complications were categorized as “early” (ie, first 30 days) or “late” (ie, after 30 days). Potential early complications include hematoma, skin necrosis, infection, and nipple loss. Potential late complications include recurrent breast ptosis, poor shape of the nipple areolar complex, hypertrophic scarring, implant rupture, capsular contracture, decreased nipple sensation, implant extrusion, reoperation, and scar revisions. The key principle of the technique is to place the breast implant in the dual plane first, and then perform the tailor tacking of the skin for the mastopexy second.

Results:

Fifty-six consecutive patients underwent augmentation and mastopexy over 8 years with this technique. The average age of the studied patients was 41.2 years. The average follow-up time period was 2.1 years (±8.9 months). Fifty-four patients (96.4%) had implants placed through the periareolar approach, 2 patients (3.6%) had implants placed via the inframammary approach. All implants were placed in a dual plane. Fifty-two patients (92.9%) received silicone implants and 4 patients (7.1%) received saline implants. Patient preference determined implant choice. All but 5 patients had textured implants. Average implant size was 277 cm³ (range 120–800 cm³). Ten patients had complications (17.9%). Complications included hypertrophic scarring in 5 (8.9%) patients; poor nipple-areola complex shape in 4 patients (7.1%); implant ruptures in 3 patients (5.4%); capsular contracture in 3 patients (5.4%); and recurrent ptosis in 2 patients (3.6%). There were no reported early complications such as nipple loss, breast skin necrosis, decreased nipple sensation, implant infections, or extrusions. However, 6 patients (10.7%) required return trips to the operating room for revisions, and 1 patient (1.8%) had a nipple areolar complex scar revised in the office, yielding a 12.5% surgical revision rate for the late complications.

Conclusions:

It is safe to concurrently perform mastopexy and breast augmentation. In our 8-year review, there were no early catastrophic complications such as skin loss, nipple loss, implant extrusion, or infection. The complications that occurred were the same complications known to occur with the independent performance of mastopexy alone or breast augmentation alone, and they occurred at rates comparable to or less than the national averages for those procedures when they are performed independently. The paramount principle for the success of this technique is to first adjust breast volume and then perform an intraoperatively determined skin resection to fit the new breast volume.

Getting the Most Out of Augmentation-Mastopexy

LEARNING OBJECTIVES

After reviewing the article, the participant should be able to: 1. Understand the tenets of proper patient selection. 2. Be familiar with the assessment of patients for augmentation-mastopexy. 3. Be able to plan an operative approach and execute the critical steps. 4. Be able to recognize common complications and have a basic understanding of their management. 5. Be aware of emerging adjunctive techniques and technologies with respect to augmentation-mastopexy.

SUMMARY

Despite being a multivariable and complex procedure, augmentation-mastopexy remains a central and pivotal component of the treatment algorithm for ptotic and deflated breasts among plastic surgeons. Careful preoperative planning, combined with proper selection of approach and implant, can lead to success. Physicians need to understand that there is a high frequency of reoperation cited in the literature with regard to this procedure, and discussions before the initial operation can help alleviate common misunderstandings and challenges inherent in this operation.

The Balcony Technique of Breast Augmentation and Inverted-T Mastopexy With an Inferior Dermoglandular Flap

BACKGROUND

Optimal breast augmentation-mastopexy involves a reliable technique, fast recovery, minimal complications, and aesthetic results that are excellent and enduring.

OBJECTIVES

The authors sought to determine whether the balcony technique of augmentation-mastopexy was safe and yielded satisfactory long-term outcomes in patients with breast ptosis and hypoplasia.

METHODS

The authors conducted a retrospective review of 207 patients who underwent subglandular augmentation and inverted-T mastopexy with a customized Wise keyhole resection pattern and an inferior flap. Patient satisfaction was assessed anonymously on a visual analog scale via a questionnaire administered 4 years postoperatively.

RESULTS

A total of 182 women received follow-up for 48 months and were included in statistical analyses. High levels of satisfaction were determined using Fischer exact test for breast shape, size, and symmetry, but not for other items, such as scar appearance, body perception, or self-esteem. The most common complications were Baker II capsular contracture and wound dehiscence. No patient experienced nipple loss or skin flap necrosis.

CONCLUSIONS

The results of this long-term analysis demonstrate that the balcony technique of augmentation-mastopexy is suitable for patients with breast ptosis and hypoplasia.

LEVEL OF EVIDENCE

4.

Use of Poly-4-Hydroxybutyrate Mesh to Optimize Soft-Tissue Support in Mastopexy: A Single-Site Study

BACKGROUND

The ptotic breast is surgically rejuvenated through a mastopexy procedure. Recurrent ptosis or other negative changes to the breast shape are not uncommon following mastopexy, as the tissue laxity and skin quality that contributed to ptosis are not surgically corrected. The purpose of this study was to assess the postsurgical changes in the breasts of patients who underwent a primary mastopexy procedure with soft-tissue reinforcement using a long-term poly-4-hydroxybutyrate resorbable scaffold (i.e., GalaFLEX).

METHODS

From July of 2012 to January of 2014, 11 consecutive patients underwent a central mound mastopexy with soft-tissue reinforcement in the lower pole using a poly-4-hydroxybutyrate resorbable scaffold. Patients returned for postoperative follow-up visits that included three-dimensional scans of their breasts at months 1, 3, 6, and 12.

RESULTS

There were no major complications in the study. Changes in the breast shape defined by distances between predefined landmarks between months 1 and 12 ranged from 1.5 to 9.6 percent. Some postoperative breast settlement occurred between months 1 and 3. The mean change in the nipple-to-inframammary fold distance from months 1 to 12 was 8 mm. Lower pole stretch was 5 percent.

CONCLUSIONS

Initial findings suggest that central mound mastopexy with soft-tissue reinforcement in the lower pole performed on difficult larger breasts yields a relatively stable result for 1 year after surgery. There was no statistically significant change between months 3 and 12 from the sternal notch to lowest point on the breast as determined by established three-dimensional imaging techniques.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

All Seasons Vertical Augmentation Mastopexy: A Simple Algorithm, Clinical Experience, and Patient-reported Outcomes

Supplemental Digital Content is available in the text.

Background:

The safety of augmentation mastopexy has been questioned. Staging has been recommended for women deemed to be at higher risk, such as women with greater degrees of ptosis. Most existing studies evaluate women treated with multiple methods, including the traditional Wise pattern. This retrospective study specifically evaluates vertical augmentation mastopexy. A simple algorithm is introduced.

Methods:

From 2002 to 2016, 252 women underwent consecutive vertical augmentation mastopexies performed by the author, with no staged surgery. All patients underwent a vertical mastopexy using a medially based pedicle and intraoperative nipple siting. A subset of women treated from 2012 to 2016 were surveyed to obtain outcome data; 90 patients (inclusion rate, 90%) participated.

Results:

The complication rate was 32.9%, including persistent ptosis, delayed wound healing, scar deformities, and asymmetry. There were no cases of nipple loss. An increased risk of complications was detected for smokers (P < 0.01), but not for combined procedures, secondary breast augmentations, or secondary mastopexies. The revision rate was 15.5%. Persistent nipple numbness was reported by 13.3% of respondents. Eighty percent of women were self-conscious about their breast appearance before surgery; 22% of respondents were self-conscious about their breasts after surgery. Seventy percent of respondents reported an improved quality of life, 94.4% would repeat the surgery, and 95.6% would recommend it.

Conclusions:

A simple algorithm may be used to guide treatment in women who desire correction of ptosis and upper pole fullness. An "all seasons" vertical augmentation mastopexy is safe and widely applicable. Staging is unnecessary.

The Delay Fill Technique: A Safer Approach to Combination Augmentation Mastopexy

Combining breast augmentation with mastopexy is a challenging procedure that has a relatively high revision rate in the literature. Some surgeons prefer a two-stage procedure to avoid the potential for skin flap or nipple-areolar complex necrosis that can occur with a one-stage procedure. The authors compared 101 patients who had subpectoral breast augmentation with immediate implant fill and mastopexy with 203 patients who had subpectoral breast augmentation with delayed (10-14 days) implant fill and mastopexy. They found the revision rate for immediate implant fill was 24%; in the delayed implant fill group, the revision rate was 10.3%. Patients had soft tissue-related complications in 16% of the immediate fill group and in 2% of the delayed fill group. Delaying implant fill in combined breast augmentation mastopexy significantly reduces the risk of soft tissue-related complications and revision procedures; the delay flap phenomenon is responsible for fewer wound-healing complications when implant fill is delayed during a combined augmentation mastopexy procedure.

Safety of vertical augmentation-mastopexy: prospective evaluation of breast perfusion using laser fluorescence imaging

BACKGROUND

Augmentation-mastopexy is often recommended to simultaneously correct breast ptosis and restore upper pole fullness. However, some investigators believe that this procedural combination increases risk and recommend staging the surgery for some patients.

OBJECTIVES

This prospective study was undertaken to evaluate the blood supply of the breast and, specifically, the nipples and areolae to determine whether breast implants inserted at the time of a vertical mastopexy compromise blood supply.

METHODS

The SPY Elite Intraoperative Perfusion Assessment System was used to provide objective measurements of skin perfusion during surgery. To avoid confounding variables, patients served as their own controls. Twenty-five women (50 breasts) meeting the inclusion criteria (inclusion rate: 96%) were studied. All patients underwent bilateral vertical augmentation-mastopexies using a medial pedicle. No surgery was staged. The mean implant volume was 360 cc (range, 180-575 cc). The breasts were imaged in surgery after completion of bilateral mastopexies with insertion of (unfilled) saline breast implants and a second time after inflation of the implants.

RESULTS

Complications included 1 distal deep venous thrombosis, 1 infection, 1 partial areola necrosis, and 1 case of delayed wound healing. There was no significant difference (P < .01) in intraoperative perfusion measurements comparing absolute and relative values before and after breast implant inflation (saline-filled implants) or insertion (silicone gel implants), including 5 patients undergoing secondary mastopexies.

CONCLUSIONS

The insertion of breast implants at the time of a vertical mammaplasty with a medial pedicle does not significantly reduce perfusion of nipple/areola complexes. Staging the procedure is unnecessary.

LEVEL OF EVIDENCE

4 Therapeutic.

Augmentation mammoplasty/mastopexy: lessons learned from 107 aesthetic cases

BACKGROUND

One-stage augmentation/mastopexy entails the challenge of augmenting breast volume with an implant while resecting excess skin. Although both augmenting and lifting the breast in a one-stage operation is gaining in popularity, its safety and its efficacy are still under debate and merit deeper evaluation.

METHODS

We retrospectively reviewed our experience over a 5-years period with patients who underwent augmentation mammoplasty/mastopexy with the specific objectives of documenting their outcomes and formulating algorithms for safe, simple, and effective operative strategies to manage such patients. Our surgical approach to augmentation/mastopexy breast ptosis was described step by step. Patient satisfaction with the results was also evaluated.

RESULTS

One hundred seven patients underwent successful simultaneous augmentation/mastopexy surgery. Sixty-nine underwent primary breast surgery and 38 underwent secondary breast surgery. In 12 cases a periareolar mastopexy scar was used, while in 51 patients a vertical approach was preferred; in 11 and 33 patients a short "T" and an inverted "T" scar mastopexy was necessary, respectively. Few complications were observed, with a very low overall complication rate (14 %) and a reoperation rate of 12.1 % at 14.7 months. Patient satisfaction with the results of this procedure was extremely high.

CONCLUSIONS

Simultaneous augmentation/mastopexy is an effective and versatile way to lift the NAC, tighten the breast skin, increase breast projection, and fill in the upper pole. Our technique of simultaneous breast mastopexy after augmentation through a lower periareolar approach showed excellent correction of pre-existing ptosis, making this method highly reliable because the intraoperative tailor-tacking was customized to the patient, implant size, and projection.

Augmentation mastopexy: maximal reduction and stable implant coverage using four flaps

BACKGROUND

A single-stage operation to correct ptotic and hypoplastic breasts would appear to be a very appealing option for both surgeons and patients. However, this procedure is the most often litigated in aesthetic surgery because of its frequent complications. Our goal in this article is to report our experience with a four-flap technique for implant coverage in maximum reduction mastopexy with prosthesis.

METHODS

From January 2011 to March 2013, a total of 41 patients with Regnault grade II or grade III ptosis with no hypertrophy underwent primary bilateral augmentation mastopexy. Our technique includes an inverted-T mastopexy and a thin, well-vascularized, inferior dermoglandular flap to cover the inferior pole of the implant. Retrospective data collection revealed a mean patient age of 37.5 years. Thirty-nine patients were treated with round cohesive silicone gel implants and two with anatomical cohesive gel implants. The mean implant volume was 280 cc and mean follow-up time was 14 months.

RESULTS

The following complications were observed in declining frequency: four suture dehiscences, two hematomas, one capsular contracture, one implant malposition, and one poor scarring. A satisfaction questionnaire revealed very high satisfaction in 23 patients (56.09 %), high satisfaction in 12 (29.26 %), moderate satisfaction in four (9.75 %), and low satisfaction in two (4.87 %).

CONCLUSIONS

Our results demonstrated a low complication rate (21.9 %) and low reoperation rate (12.1 %) with our technique and make us confident in recommending this technique for grade II and grade III ptosis.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266 .

Prospective comparative clinical evaluation of 784 consecutive cases of breast augmentation and vertical mammaplasty, performed individually and in combination

BACKGROUND

Despite the growing popularity of breast lift surgery, no published study prospectively evaluates mastopexy and augmentation/mastopexy. Several investigators suggest an inordinate risk in combining augmentation and mastopexy, and recommend staging the surgery in some patients. However, no existing study includes the necessary individual and combined treatment cohorts to allow reliable comparisons of safety and efficacy. This study investigates the clinical outcomes and safety of these cosmetic breast procedures, whether performed individually or in combination.

METHODS

This 10-year prospective study evaluated 759 consecutive women undergoing 784 consecutive cases of breast augmentation (n = 522), mastopexy (n = 57), augmentation/mastopexy (n = 146), reduction (n = 48), and reduction plus implants (n = 11). All patients were treated by the author using submuscular implant placement and vertical parenchymal resection with a medial pedicle and intraoperative determination of nipple positioning. A power analysis confirmed adequacy of the sample sizes.

RESULTS

The complication rate was 36.3 percent for augmentation/mastopexy, 33.3 percent for mastopexy alone, and 17.6 percent for breast augmentation alone. Mammaplasties were complicated by persistent ptosis in 9.5 percent of patients. The revision rate after augmentation/mastopexy was 20.5 percent, compared with 24.6 percent for mastopexy and 10.7 percent for breast augmentation.

CONCLUSIONS

Vertical mammaplasty may be used to correct ptosis in breasts of all sizes. Vertical augmentation/mastopexy provides complication and revision rates that are less than the calculated cumulative rates for the procedures performed separately. The combined procedure offers technical advantages and permits safe single-stage surgery using the vertical technique.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Simultaneous augmentation mastopexy: a technique for maximum en bloc skin resection using the inverted-T pattern regardless of implant size, asymmetry, or ptosis

BACKGROUND

Simultaneous augmentation mastopexy for moderately to severely ptotic breasts presents the challenge of determining how much excess skin should be removed after implant placement to create symmetry and provide for maximal skin tightening without compromising tissue vascularization.

METHODS

Simultaneous augmentation mastopexy involves invagination and tailor tacking of the excess skin after implant placement and then making a pattern around the tailor-tacked tissues for previsualization of the total area to be resected. This contrasts with first making a pattern for the mastopexy, resecting the skin, and then tailor tacking the tissues together. Over a 7-year period, 55 women had simultaneous augmentation mastopexy with this approach. Saline implants were placed in the subpectoral dual-plane position before the mastopexy was started. All surgeries were performed with the patient under general anesthesia, and the patients were discharged the same day. In a retrospective chart review, breast implant size, degree of preoperative asymmetry, length of procedure, and complications were recorded. The patient follow-up period ranged from 3 months to 7 years (median, 9 months).

RESULTS

Symmetric, aesthetic results were achieved for all the patients. The range of saline implants used was 375-775 ml (average, 500 ml). Of the 55 women, 15 had two different size implants measuring at least 50 ml or larger, with the greatest size disparity in a patient being 225 ml (left breast, 700 ml; right breast, 475 ml). Six of the patients (10.9%) had small areas that healed by secondary intention, occurring mostly at the inferior junction of the inverted T. Only two patients (3.6%) had recurrence of breast ptosis, and only one patient (1.8%) had a mildly hypertrophic scar. There were no incidences of hematoma, infection, rippling, malposition of the nipple-areolar complex (NAC), NAC loss, capsular contraction, implant malposition, or dissatisfaction with implant size. The bilateral augmentation/mastopexy surgery time ranged from 2 h and 29 min to 4 h and 30 min (average, 3 h and 8 min).

CONCLUSIONS

The described technique maximizes the amount of tissue to be resected in simultaneous augmentation mastopexy for moderately to severely ptotic breasts. Symmetry is more easily achieved with this approach regardless of the implant size used or the amount of skin to be resected. This technique minimizes the chance of tissue necrosis from devascularized skin edges. It also may shorten the inverted T scar and reduce the operative time.

Successfully exploiting two opposing forces: a rational explanation for the "interlocking suture"

BACKGROUND

Issues of poor circumareolar scars and asymmetry or malposition of the nipple-areola complex (NAC) are frequently associated with those breast reduction or pexy techniques that rely on an ample excision of skin around the areola, either alone or associated with a vertical scar in a circumvertical approach. To prevent such problems, in 2007 Hammond et al. introduced the "interlocking suture." The objective of this study was to demonstrate the true ability of this suture to reduce the common complications of periareolar surgery simply by managing the existing contrast between NAC centripetal and outer breast tegument centrifugal forces.

METHODS

By using finite element method (FEM) software, the NAC traditional interrupted stitches were compared with both round-block and interlocking sutures, and the skin strain in all three procedures was qualified.

RESULTS

The contribution of circuitous stitches in the interlocking suture leads to a more advantageous distribution of forces. FEM analysis shows that the interlocking suture reduces skin stress on peripheral breast teguments by 14% compared to the round-block suture and by 15% compared to the traditional (radial) suture. When evaluating the areolar edge, the interlocking suture leads to a reduction in skin stress of 9.9% compared with traditional interrupted stitches.

CONCLUSIONS

The efficient, long-lasting results of the interlocking suture are directly due to its unique design, which effectively reduces the tension between the NAC and breast tegument edges in periareolar surgery, thus improving the quality of the scar.