Breast autoaugmentation

A technique using a posteriorly based dermoglandular flap as an augmentation of the superior hemisphere of the breast combined with a periareolar mastopexy and vertical mastopexy is presented. The advantages of combining a periareolar mastopexy, in terms of reducing the length of the vertical scar and preventing areolar distortion, are explained.     

改良双环法乳房下垂矫正术

目的:介绍改良双环法行乳房悬吊术的方法和经验。方法:采用传统的双环法环乳晕切口,切除双环间表皮,在皮肤与上半乳腺的腺体表面之间剥离,去除上半腺体后松弛的浅筋膜深层,上提腺体至正常位置并固定于深筋膜,同时进行腺体的适当折叠塑形或置入乳房假体增加丰满程度。结果:共行轻、中度下垂28例(4例为单侧下垂),其中悬吊加假体隆乳9例;腺体瓣交叉缝合悬吊塑形19例。术后乳房外形改善满意,乳头、乳晕感觉良好,效果持久。结论:本手术方法安全易行,组织损伤小,瘢痕不明显,是矫治轻、中度乳房下垂的一种比较理想的方法。     

An Uncommon Complication of Secondary Augmentation Mammoplasty:Bilaterally Massive Engorgement of Breasts After Pregnancy Attributable to Postinfection and Blockage of Mammary Ducts

Augmentation mammoplasty is one of the most frequently performed aesthetic operations. Galactorrhea and galactocele formation after augmentation mammoplasty, while the patient is experiencing the hormonal effects, is rarely seen. The cause remains unknown. However, postoperative fibrosis and blockage of the mammary ducts after augmentation mammoplasty is a probable cause of this formation in some patients. In the reported case, the patient described painful massive engorgement of both breasts during the last month of pregnancy and inability to breast-feed after delivery. In her history, she had undergone breast augmentation via the semicircular periareolar transglandular approach. She had experienced an infection at an early stage of her postoperative period and had needed to have both prostheses removed. A second breast augmentation mammoplasty was performed 1 year after the first operation via the same incision. She was content with the result of her second augmentation mammoplasty, up until her third pregnancy, at which time she reported inability to breast-feed after her delivery. At our examination, it was determined that there was massive painful breast engorgement, hyperemia, and inflammation of both breasts attributable to a bilateral galactocele formation. She refused to take any medication (bromocriptine), but approved antibiotic treatment. The patient responded to the antibiotics, and the prostheses therefore were left in place without further complications.     

乳房下垂矫正术中的乳房悬吊结构重建

目的总结用乳房悬吊结构重建方法矫正轻、中度乳房下垂的临床经验。方法通过乳晕边缘切口，去除上半腺体后松弛的浅筋膜深层，上提腺体至正常位置并固定于深筋膜，腺体浅面按真皮乳罩原理进行悬吊并适当切除乳晕周边多余皮肤，或采用聚丙烯单丝网片对腺体进行悬吊，术后腺体周围形成强大的纤维粘连，从而重建乳腺的悬吊支持结构。同时进行腺体的适当折叠塑形或置入乳房假体增加丰满程度。结果共行轻、中度下垂32例手术（其中单纯悬吊10例，悬吊同时假体隆乳20例，采用聚丙烯网片悬吊2例），手术时间90～150min，平均110min。术中出血量30～100ml，平均58ml。均未发生乳头乳晕坏死感觉障碍等并发症。术后随访6～12个月，平均11．3月，术后外形改善满意率90．6％（29／32）。结论对于不伴腺体肥大的乳房轻、中度下垂，采用乳房悬吊结构重建，是一种创伤相对小，安全，有效的矫正方法。     

绕乳头基底乳晕纵切口结合肿胀麻醉隆乳术

目的：探讨绕乳头基底乳晕纵切口结合肿胀麻醉隆乳术的操作技巧及此方法的优点。方法：对我科39例腋下切口、15例乳房皱襞下切口、27例乳晕下缘弧形切口及35例绕乳头基底乳晕纵切口结合肿胀麻醉的116例隆乳患者的疗效及患者满意度进行比较。结果：采用绕乳头基底乳晕纵切口患者的疗效及满意度最高。结论：绕乳头基底乳晕纵切口结合肿胀麻醉是理想的隆乳术式,手术创伤小,切口隐蔽,易于操作,术后患者恢复快,形态好。     

Augmentation Mastopexy with Implant and Autologous Tissue for Correction of Moderate/Severe Ptosis

Purpose: Breast augmentation combined with mastopexy is associated with a significantly higher complication rate than augmentation alone. The combination of mastopexy and breast implants has revealed a moderate recurrence of breast ptosis in many patients particularly with use of medium to large implants. Ptosis is the “bottoming out” of the breast tissue with loss of the desired roundness, due to the ptosis of the breast implant and the mammary tissue. In this study, we hypothesize the need for careful planning and careful preoperative surgical execution to minimize this complication. Patients and Methods: Between January 2007 and July 2011, augmentation mastopexy with implant and autologous tissue (“double implant”) was performed for 25 patients with grade III mammary ptosis. All patients underwent inverted-T mastopexy with supramuscular moderately cohesive gel breast implant using an inferior-based flap of de-epitelialized dermoglandular tissue and a superior-based nipple-areola complex pedicle. Results: An inferior-based flap of deepithelialized dermoglandular tissue was used to stabilize the implant and is projection. Breast lifting was performed through a strong anchorage to fascia and to muscle of second intercostal space, improving the profile of the breast. Results were analyzed, no breast ptosis recurrence was noted at 30-month follow-up. Conclusions: Our technique presents the challenge of determining the amount of excess skin to be removed after implantation to create symmetry and provide for skin tightening without compromising tissue vascularization.     

Radial Plication in Concentric Mastopexy

Concentric mastopexy presents many challenges to the plastic surgeon, especially when breast augmentation is part of the treatment plan. Radial plication is a reproducible and accurate technique for elevating the nipple–areolar complex and shaping the breast mound. Patient selection is important to the success of the radial plication procedure and concentric mastopexy in general. Although most surgeons agree that patients with smaller degrees of nipple ptosis and smaller breasts have better results than patients with greater degrees of nipple ptosis and larger breasts, there has never been an algorithm for patient selection. Regnault’s classification of breast ptosis addresses the degree of nipple ptosis, but no consideration is given to breast volume. Radial placation proved to be a valuable tool in the treatment of 87 patients undergoing concentric mastopexy in the author’s practice over the past 30 months. An algorithm addressing degrees of breast ptosis and breast volume is provided. The plastic surgeon can anticipate gratifying results if the algorithm provided is incorporated into his or her patient selection for concentric mastopexy. The concentric mastopexy technique is similar to the tailor tack procedure for standard mastopexy, allowing the plastic surgeon to mold and shape the breast before making a critical incision.     

The versatility of the inferior dermal flap in implant/expander-based immediate breast reconstruction and its application in augmentation–mastopexy

The inferior dermal flap technique with the Wise pattern skin resection has been used in the authors practice, mainly in patients who required bilateral or unilateral risk-reducing mastectomy for prophylaxis. The versatility of this procedure allowed the senior authors (MPS and PL) to extend its applicability for vertical scar augmentation–mastopexy in asymmetrical breast and for Wise pattern skin resection mastopexy–augmentation in massive weight loss. Between 2006 and 2009, the inferior dermal flap was performed in 18 patients with a total of 34 breasts, 20 of which had the Wise pattern skin resection following risk-reducing mastectomy, two of which were unilateral, six had a Wise pattern skin resection after massive weight loss and six had a vertical skin excision for asymmetrical breasts. No haematoma, infection or seroma were seen with this technique. No breakdown at the T junction was reported. One patient had a capsular contracture which required a capsulectomy and replacement of implants. We report our experience of this technique in patients undergoing unilateral skin-reducing mastectomies for prophylaxis and we demonstrate the versatility of the dermal flap when applied for vertical scar augmentation–mastopexy in the asymmetrical breast and for Wise pattern skin resection mastopexy–augmentation in massive weight loss.     

A Systematic, One-stage Approach in the Treatment of Tuberous Breast Deformity

During a 2-year period, we performed a single-stage procedure on 7 patients with unilateral “tuberous” breasts after thorough analysis of the deformity and the contralateral breast. Deficient breast envelope skin was replaced by use of a laterally based random inframammary cutaneous flap. Breast tissue rearrangement with or without augmentation was required to address the parenchymal maldistribution and volume abnormalities. Associated tuberous breast ptosis was adequately corrected by tissue rearrangement, augmentation, and circumareolar mastopexy. Areola herniation and size were adjusted by performing a circumareolar mastopexy. Relocation of the inframammary crease was necessary to achieve symmetry. There were two complications in two patients: In one patient a staphylococcal infection developed in the breast pocket after a traumatic hematoma that occurred 2 weeks after surgery. Another patient required implant exchange for a smaller one to achieve better symmetry. Nipple sensation was not affected adversely by the surgery. Ultimately, all patients achieved acceptable symmetry and were satisfied with the results.     

Treatment of tuberous breasts utilizing tissue expansion

This article presents the tissue expansion technique for the treatment of the tuberous breast and its variant, the tubular breast. The treatment objectives are different in the two deformities, but, in general, one has to expand the base circumference of the breast, expand the skin of the lower hemisphere of the breast, release the skin tightness at the skin-areola juncture, lower the position of the inframammary fold, increase the volume of the breast skin envelope, reduce the size of the areola and correct its deformity, and perform a mastopexy when necessary. To achieve these objectives, we use a tissue expander introduced either beneath the breast or beneath the pectoral muscle through an incision along the inframammary fold. It is slowly expanded to the appropriate volume. The reconstruction is completed at the second stage when the size of the areola is reduced, the expander is exchanged for an implant, or the fill-port is removed. The tissue "herniation" is corrected and a mastopexy is performed when necessary. We treated seven tuberous breasts and three tubular breasts by the two-stage method. Eight reconstructions were completed successfully in two stages. An additional operation became necessary in two cases; one to treat an exposed expander, and another to correct a capsular contracture. The results have been uniformly good and compare favorably with those presented in the literature done by other methods. We recommend use of the combination expander/implant.     

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.

     

Relationship of Incision Choice to Capsular Contracture

Background Capsular contracture can be an ongoing problem in breast augmentation even with good surgical technique. In the author’s practice, a higher incidence of capsular contracture was observed with the use of a periareolar incision than with an inframammary incision. Methods A review of breast augmentations performed from November 2004 through June 2006 was conducted. This analysis included the incision used, the procedure performed, and the development of capsular contracture. Results The incidence of contracture was 0.59% in the inframammary group and 9.5% in the periareolar group. This increase in capsular contracture with a periareolar incision was statistically significant. Capsular contracture occurring with augmentation performed at the time of a periareolar mastopexy was 8%, which was statistically significant compared with the inframammary group. The difference in contracture rates between a periareolar incision alone and a periareolar mastopexy was not statistically significant. Conclusions Breast augmentation through a periareolar incision has a higher incidence of capsular contracture than observed with an inframammary incision. This most likely occurs due to an increase in contamination of the breast pocket with intraductal material colonized by bacteria. The periareolar incision is, and will remain, a standard of care. Therefore, this information can help clinicians make a more informed decision regarding incision placement for breast augmentation. Presented at the annual meeting of the Texas Society of Plastic Surgeons, September 30, 2007.     

Unsatisfactory results of periareolar mastopexy with or without augmentation and reduction mammoplasty: enlarged areola with flattened nipple

A method of repair is described for correction of abnormally enlarged nipple–areola complex following both periareolar mastopexy and pregnancy. Although during periolar mastopexy or reduction mammoplasty regular subcuticular dermal sutures may control the enlargement of nipple–areola complexes initially, the periareolar scar becomes hypertrophic and areolar spreading occurs to some extent. Periareolar mastopexy techniques are indeed advisable only for minimal hypertrophies or ptosis of the breast, especially for areolar asymmetry, if an acceptable, normal-size areola is expected. The authors believe that in periolar mastopexy or reduction mammoplasty cases resulting in enlarged nipple–areola complexes, the size of the areola can also be corrected by reduction mammoplasty or mastopexy using vertical bipedicle techniques. Although surgery results in an inverted T incision, the shape of the breast is more acceptable and the size of the areola does not enlarge with time.     

Treatment of tuberous breasts utilizing tissue expansion

This article presents the tissue expansion technique for the treatment of the tuberous breast and its variant, the tubular breast. The treatment objectives are different in the two deformities, but, in general, one has to expand the base circumference of the breast, expand the skin of the lower hemisphere of the breast, release the skin tightness at the skin-areola juncture, lower the position of the inframammary fold, increase the volume of the breast skin envelope, reduce the size of the areola and correct its deformity, and perform a mastopexy when necessary. To achieve these objectives, we use a tissue expander introduced either beneath the breast or beneath the pectoral muscle through an incision along the inframammary fold. It is slowly expanded to the appropriate volume. The reconstruction is completed at the second stage when the size of the areola is reduced, the expander is exchanged for an implant, or the fill-port is removed. The tissue herniation is corrected and a mastopexy is performed when necessary. We treated seven tuberous breasts and three tubular breasts by the two-stage method. Eight reconstructions were completed successfully in two stages. An additional operation became necessary in two cases; one to treat an exposed expander, and another to correct a capsular contracture. The results have been uniformly good and compare favorably with those presented in the literature done by other methods. We recomment use of the combination expander/implant.     

Augmentation Mastopexy in Muscle-Splitting Biplane: Outcome of First 44 Consecutive Cases of Mastopexies in a New Pocket

Background  

Augmentation with mastopexy is a commonly performed procedure and is done either simultaneously or in stages. The augmentation component can be accomplished by placing an implant in the subglandular, partial submuscular, or subfascial plane, and mastopexy can be performed using periareolar, vertical, or Wise pattern markings. These two components are independent of each other and any pocket can be combined with suitable external markings. The muscle-splitting submuscular biplane is a new pocket and is combined with conventional envelope reductions for mastopexy.     

双平面隆乳术在矫治小乳症并乳房下垂中的应用

目的：讨论双平面隆乳术在矫治小乳症并乳房下垂中的临床应用。方法：选择22例患者,4例哺乳后乳房萎缩并松垂行单纯双平面隆乳术,18例小乳症并乳房Ⅰ度至Ⅲ度下垂行双平面硅胶假体隆乳及乳房下垂矫正。结果：22例术后随访1个月至1年2个月,平均6．5个月。20例（40只）乳房形态良好,无假体移位、包膜挛缩及畸形。1例（2只）Ⅲ度乳房下垂者因悬吊不够,9个月随访时仍呈现Ⅰ度下垂。1例（1只）乳房硬化,为BakerⅢ。讨论“双平面”法隆乳术,即假体同时位于两个平面（部分位于乳腺下,部分位于胸大肌下）,此方法适用于各类乳房,能避免“双乳房”畸形,术后乳房下部形态美观。     

Circumareolar Dermo-Glandular Plication: A New Concept for Correction of Breast Ptosis

Circumareolar dermo-glandular plication is the latest advancement of the periareolar dermopexy with a retromammary mastopexy technique I published in 1969. Rather than a technique, the new concept is a procedure which originates new techniques covering multiple indications, i.e. for all conditions combined with ptosis: for mastopexy in ptotic breasts, for hypertrophic or hypoplastic breasts with resection or implant augmentation, respectively; for subcutaneous mastectomy, gynecomastia, asymmetries, and tuberous breasts. It is useful for reoperations to correct secondary ptosis as well as to reduce the length of the scar in vertical techniques. The corresponding techniques are described. The procedure has proved to be safe and reliable in over 200 patients with the following advantages: no full thickness skin incision or excisions are performed; only the epidermis is excised. Except for hypertrophies, the skin is not dissected from the gland, nor the gland from the pectoralis fascia, which increases vascular safety and preserves NAC innervation; the dermoglandular unit of the breast through Cooper's ligaments is stabilized by a single or multiple plications. The scar is only circumareolar, reducing psychological stress and discomfort and achieving an early recovery and patient satisfaction. The inconveniences are puckering and some widening of the periareolar scar, which requires a secondary revision in approximately 50% of the cases, also frequently necessary in conventional techniques. There is a tendency to flattening of the NAC and periareolar bulging with tendency to a ``tomato breast appearance.' The prevention of the latter is described.     

乳房皮下切除与自体组织即刻乳房再造

目的探索乳房皮下切除与几种方法的乳房再造术，即腹直肌肌皮瓣或背阔肌肌皮瓣加乳房假体或局部皮瓣等即刻再造乳房的方法。方法选择乳腺导管内原位癌10例和巨大乳腺良性肿瘤5例，顺乳晕切口活检，病理检查确立诊断后，采用经乳腺切口行乳癌或巨大肿瘤的乳房皮下切除术，若乳癌或良性肿瘤体积较大，另于腋窝部加做顺腋下皱襞的附加切口，以便于取出切除的组织及切除乳腺的腋尾部，同时可以切取腋淋巴结行冰冻切片活检。然后，应用腹直肌肌皮瓣或背阔肌肌皮瓣加乳房假体或局部皮瓣即刻行再造乳房，充填乳房切除后的空间，仅以少量的肌皮瓣皮肤修复乳头、乳晕切除后的缺损，并在此转移皮瓣上再造乳头、乳晕。结果经过多专科协作共完成15例，随访结果良好，无肿瘤复发。此法再造的乳房易与健侧乳房对称，保留了原有乳房皮肤的良好感觉，外观形态自然，再造乳房瘢痕较少，且手术切口瘢痕隐蔽。结论在严格选择手术适应证防止乳腺癌复发的前提下，乳房皮下切除与即刻乳房再造法，对乳腺导管内原位癌和巨大乳腺良性肿瘤患者I期完成肿瘤切除和乳房再造术，具有积极有效的意义。     

Combining muscle-splitting biplane with multilayer capsulorrhaphy for the correction of bottoming down following subglandular augmentation

Implant malplacement is the second most common reason for revision and bottoming down is the most common presentation of implant malplacement. Submuscular biplane relocation was combined with capsulotomies and multilayer capsulorrhaphy when bottoming down was seen following subglandular breast augmentation. Between 2005 and 2009, bottoming down following subglandular mammoplasty was seen in 41 breasts (19 bilateral and three unilateral). Of the 19 patients, 12 had downward transgression of inframammary crease (IMC) alone; this also included a patient with vertical scar mastopexy. Two patients had multiplane malplacements where bottoming down was associated with lateral displacement (telemastia) in one and medial displacement (symmastia) in the other. Two had simultaneous downward transgression of the IMC and nipple areolar complex (NAC) and three had bottoming down with capsular contracture independent of NAC descent. Follow-up of up to 3 1/2 years showed stable IMC and NAC relationship with acceptable results. Dog ear revision was required in one patient when IMC relocation was accompanied with vertical scar mastopexy and one patient needed revision for further relocation and improvement of symmastia. No wound breakdown or periprosthetic infection was seen in their series. Multilayer capsulorrhaphy with submuscular biplane repositioning of implants is a suitable option to correct bottoming down following subglandular augmentation.