Inferior Pedicle Autoaugmentation Mastopexy After Breast Implant Removal

Background  

A new method of autoaugmentation mammaplasty is presented to correct ptosis and to increase the projection and volume of the breast in patients who would like a reposition augmentation mammaplasty after breast implant removal but do not want a new implant.     

The Lateral Inframammary Fold Incision for Nipple‐Sparing Mastectomy: Outcomes from Over 50 Immediate Implant‐Based Breast Reconstructions

Nipple‐sparing mastectomy (NSM) as a therapeutic or prophylactic procedure for breast cancer is rapidly gaining popularity as the literature continues to support it safety. The lateral inframammary fold (IMF) approach provides adequate exposure and eliminates visible scars on the anterior surface of the breast, making this incision cosmetically superior to radial or periareolar approaches. We reviewed 55 consecutive NSMs performed through a lateral IMF incision with immediate implant‐based reconstruction, with or without tissue expansion, between June 2008 and June 2011. Prior to incision, breasts were lightly infiltrated with dilute anesthetic solution with epinephrine. Sharp dissection, rather than electrocautery, was used as much as possible to minimize thermal injury to the mastectomy flap. When indicated, acellular dermal matrix was placed as an inferolateral sling. Subsequent fat grafting to correct contour deformities was performed in select patients. Three‐dimensional (3D) photographs assessed changes in volume, antero‐posterior projection, and ptosis. Mean patient age was 46 years, and mean follow‐up time was 12 months. Twelve mastectomies (22%) were therapeutic, and the remaining 43 (78%) were prophylactic. Seven of the nine sentinel lymph node biopsies (including one axillary dissection) (78%) were performed through the lateral IMF incision without the need for a counter‐incision. Acellular dermal matrix was used in 34 (62%) breasts. Average permanent implant volume was 416 cc (range 176–750 cc), and average fat grafting volume was 86 cc (range 10–177 cc). In one patient a positive intraoperative subareolar biopsy necessitated resection of the nipple‐areola complex (NAC), and in two other patients NAC resection was performed at a subsequent procedure based on the final pathology report. Mastectomy flap necrosis, requiring operative debridement, occurred in two breasts (4%), both in the same patient. One of these breasts required a salvage latissimus dorsi myocutaneous flap to complete the reconstruction. Three nipples (6%) required office debridement for partial necrosis and operative reconstruction later. No patient had complete nipple necrosis. No statistically significant differences existed between therapeutic and prophylactic mastectomies for developing partial skin and/or nipple necrosis (p = 0.35). Three episodes (5%) of cellulitis occurred, which responded to antibiotics without the need for explantation. Morphological outcomes using 3D scan measurements showed reconstructed breasts were larger, more projected, and less ptotic than the preoperative breasts (196 versus 248 cc, 80 versus 90 mm, 146 versus 134 mm, p < 0.01 for each parameter). Excellent results can be achieved with immediate implant‐based reconstruction of NSM through a lateral IMF incision. NAC survival is reliable, and complication rates are low. blechmanplasticsurgery.com     

乳房重度下垂的直线切口法乳房成形术

目的 介绍应用直线切口法乳房成形术(Lejour法)治疗重度乳房下垂方法及效果.方法 按Lejour法设计手术切口.该类患者新乳头位置较正常人群可适当下移1～2 cm,新乳房下皱襞上移5～10 cm,通过适当下移新乳头位置及上移新乳房下皱襞达到缩短垂直切口距离.剥离乳腺组织,将下垂乳腺组织从乳腺深层固定于胸大肌第2、3肋水平.皮肤无张力缝合.结果 36例中乳房肥大者30例、体积基本正常者6例,经术后3个月至2年随访,无明显并发症,新乳房外形挺拔自然,患者满意.结论 本术式简便易行,远期效果好,可作为重度乳房下垂的术式之一.     

Short scar reduction mammaplasty in the bariatric patient

Reduction mammaplasty may be necessary even after massive weight loss. Patients typically present with unfavorable breast features such as significant loss of upper pole volume, inelastic skin, and severe ptosis. The most common approach in the United States has been the Wise-pattern inferior pedicle technique, emphasizing skin excision. This report presents the short scar vertical reduction mammaplasty approach for the bariatric patient population. It aims to demonstrate improved outcomes with less scar burden. The study included 15 women (n = 29 breast reductions) with mean age of 41.8 years. All the patients had undergone gastric bypass surgery, with mean weight loss of 109 pounds and mean body mass index of 33.3 kg/m(2). A modified superomedial pedicle vertical mammaplasty technique was used. New nipple position was placed lower than the inframammary fold in accordance with vertical lack of upper pole fullness. Suction-assisted lipectomy was used to contour the inferior pole of the breast before glandular resection. A full-thickness superomedial pedicle and median incision of the upper pole maximized pedicle safety. The mean breast resection was 605 g on the right side (range, 352-945) and 592 g on the left side (range, 360-908). Patient satisfaction was high, with pleasing and stable breast shape at long-term, and a mean patient-related aesthetic ranking of 4.3 of 5.0. No major complications were noted. It is shown that superomedial pedicle vertical reduction mammaplasty can be an alternative approach in bariatric patients, achieving long-term pleasing and stable results with significantly decreased scar burden.     

Mammaplasty: a technique of comprehensive correction of the ptotic breast

Ptosis of the breast and the optimum position of the nipple in the non-ptotic breast have been defined. A descent of the infra-mammary fold in ptosis is demonstrated: the concept of the nipple infra-mammary distance is introduced and the optimum values are defined. The principle of relocating the infra-mammary fold in any form of mammaplasty where the nipple is elevated is introduced together with a precise method for defining the new level of the infra-mammary fold in relation to the proposed size of the reconstructed breast. Emphasis is placed on the aesthetic significance of avoiding inter- and extra-mammary scarring.     

Intraoperative Modification of Pitanguy Technique of Reduction Mammaplasty for Elevation of the Nipple�CAreola Complex in Case of Severe Breast Ptosis

Background  

The Pitanguy method of reduction mammaplasty has been shown to be an anatomically safe technique in the management of the ptotic breast. However, the technique, as first described, cannot be applied in gigantomastia or severe breast ptosis cases or cases of dense parenchyma of the breast. The senior surgeon suggested an intraoperative modification of the Pitanguy method of reduction mammaplasty to make it applicable for such cases.     

The spring-back phenomenon: does the final position of the nipple areola complex correspond to the pre-operative markings in reduction mammoplasty?

This study investigates whether tissue recoil or patient intrinsic factors influence the final position of the nipple areola complex (NAC) after reduction mammoplasty. The age, pre-operative ptosis, BMI and weight of the tissue resected were recorded as patient intrinsic factors in 37 patients undergoing reduction mammoplasty. The “spring-back” value was defined as the distance from the sternal notch to a nipple landmark on the breast meridian with the patient sitting up, minus the same measurement repeated with the patient recumbent to eliminate the pull of gravity on the breast. Spring back was measured pre-operatively for the nipple and nipple mark then post-operative for the nipple. The difference in centimeters between the final post-operative distance from the sternal notch to the nipple and the level intended by the pre-operative nipple mark was termed the “judgment error.” The final position of the post-operative nipple and the judgment error was compared to the spring-back values and patient intrinsic factors. Pre-operative ptosis was statistically related to increasing patient BMI and mass of tissue resected per breast. Pre-operative spring-back values for the nipple increased with increasing ptosis, BMI and decreasing age. Spring-back values were greater in the lower pole of the breast than in the upper pole. The final position of the nipple was higher than the pre-operative mark in 65% of cases, lower in 8% and as marked in 27% of cases. The post-operative NAC was, on average, 0.6 cm higher than planned pre-operatively. The post-operative distance from the sternal notch to the nipple increased with increasing pre-operative ptosis, mass of breast tissue resected per breast and all three spring-back values. The difference between the level of the pre-operative mark and the final nipple position showed a weak correlation with post-operative spring-back values. The parameters of ptosis, BMI, weight of tissue resected per breast and pre-operative nipple spring back reflect body habitus and breast size. Spring-back values vary between the upper and lower pole of the breast. The final NAC position was higher than that intended at pre-operative marking in the majority of cases. The surgeon instinctively marks the nipple lower in patients with greater pre-operative ptosis and in whom a larger resection is anticipated. Judgment error did not relate to intrinsic factors nor to pre-operative spring-back values; hence, these parameters cannot be applied as predictive tools for more accurate pre-operative marking of the nipple position. This study suggests that the pre-operative nipple mark should be placed, with the patient sitting up, at least 23 cm from the sternal notch and 0.6 cm lower than the final position estimated using the inframammary crease as a landmark. An invited commentary on this paper is available at .     

Comparison of complications according to incision types in nipple-sparing mastectomy and immediate reconstruction

BackgroundNipple-sparing mastectomy (NSM), followed by immediate reconstruction (IR) of the breast, has become a preferred surgical procedure with good cosmesis results and patient satisfaction. However, nipple-areolar complex (NAC) ischemia and necrosis remain major problems after NSM and IR.MethodsWe retrospectively analyzed patients who underwent NSM and IR at Gangnam Severance Hospital from January 2009 to June 2018. We compared the patient characteristics and complication rate among three different incisions (inframammary fold [IMF], radial, periareolar). Additionally, we identified the risk factors of NAC necrosis.ResultsData from 290 eligible breasts in 275 patients were analyzed. Patients with IMF incision had relatively lower breast weights. The overall complication rate was the highest with periareolar incision and the lowest with IMF incision (42.6% vs. 18.8%, p < 0.001). The rate of NAC ischemia or necrosis was significantly different among the three incisions (9.7%, 17.0%, and 31.1% in IMF, radial, and periareolar, respectively; p < 0.001). Moreover, surgical treatments were more frequently needed in patients with periareolar incision. Periareolar incision, short distance from the tumor to the nipple base, and large breast weight were independent risk factors of NAC ischemia or necrosis in multivariable analysis.ConclusionsCompared with IMF incision, periareolar incision was associated with higher incidences of surgical complications and NAC necrosis. Careful consideration is needed when planning NSM in patients with a large breast volume or a tumor close to the nipple.     

Importance of pedicle length in inferior pedicle technique and long-term outcome of areola-to-fold distance

Various techniques are being used to perform reduction mammaplasty. One of the most widely used techniques is the inferior pedicle technique. To our knowledge, there are not many studies on long-term changes in areola-to-fold distance, distribution of pedicle length, and its importance. Therefore, in this study, breast volume, suprasternal notch-to-nipple distance, and nipple-to-inframammary fold distance were analyzed and the movement range of the nipple-areola complex was determined. In addition, the degree of benefit derived from the technique and the degree of long-term ptosis were investigated. The desired transposition of the nipple can be achieved by the inferior pedicle technique. The most serious complication of reduction mammaplasty is impairment of the blood supply to the nipple. However, the inferior pedicle technique has a slight possibility of causing the above complications. The most important criterion in deciding whether to perform free nipple technique or inferior pedicle technique is the pedicle length. This is a detailed study on the pedicle length and its statistical analysis.     

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.     

伴有乳房良性病变的巨乳缩小术27例

目的 探讨乳房肥大下垂同时伴有良性病变的巨乳缩小术的方法。方法：1980年11月～2001年12月，共收治乳房肥大下垂伴乳腺良性病变的患者27例52侧，根据乳腺病变的性质、部位、大小以及乳房肥大下垂的程度，选择下述不同的术式，行下方垂直蒂瓣法9例(17侧)，垂直双蒂瓣法16例(3l侧)，双环形切口乳房缩小术2例(4侧)。结果 术后外观评价良25例49侧占94．2％，差2例3侧占5．8％。术后乳房疼痛改善率为95．8％，肩、背痛，睡眠明显改善为100％，乳房下皱襞湿疹、皮炎未再发生为100％，27例患者术后着装均满意。结论 乳房缩小整形手术是治疗乳房肥大下垂，同时伴有乳腺良性病变的首选治疗方法。     

A prospective quantitative comparison of breast sensation after superior and inferior pedicle mammaplasty.

Reduction mammaplasty techniques using the inferior pedicle have been recommended to preserve the nipple and areolar sensation after surgery. The vertical scar mammaplasty with a superior pedicle has often been criticised because of the potential for damage to the sensory supply of the nipple-areola complex. The aim of this study was to assess the breast sensation in two prospective series of patients operated upon using superior pedicle and inferior pedicle mammaplasties. Between November 1996 and February 1997, 20 consecutive patients (39 breasts) underwent breast reduction using the inferior pedicle technique with inverted T scar (Robbin's technique). This series of patients was matched with another series of 18 patients (36 breasts) who had breast reduction using a vertical scar mammaplasty with superior pedicle (Lejour's technique) in another centre. Cutaneous pressure thresholds were recorded using Semmes-Weinstein monofilaments. The values were obtained on the quadrants of the skin of the breast, the areola and the nipple. The sensitivity test was performed preoperatively, then at 3 and 6 months postoperatively. Patients' characteristics (age, weight, breast ptosis, breast mass resected and risk factors) were statistically similar between the two groups. The preoperative values of pressure sensation on the different areas tested were statistically similar between the two groups. The sensitivity decreased on almost all the tested areas of the breast at 3 months postoperatively. No patient had an insensitive area on the breast at 6 months after surgery. Some areas of the breast showed a significant difference in pressure sensitivity after one technique compared to the other: better sensation on the skin of the superior and lateral quadrants after the superior pedicle technique at 3 months (P< 0.001), poorer areolar sensation on the inferior quadrant after the superior pedicle technique at 3 and 6 months (P< 0.05) and on the superior quadrant after the inferior pedicle technique at 3 months only (P< 0.05). However, the mean value of the areolar quadrants was statistically similar after both techniques. The nipple sensation was significantly decreased in both groups at 3 months but remained comparable between the two groups. Breast innervation was damaged by breast reduction using both the inferior and the superior pedicle techniques. The breast skin had better sensation after the superior pedicle technique while the areola had slightly better sensation after the inferior pedicle technique. At 6 months, the mean value of nipple-areola complex pressure sensation was comparable in the two series of patients.     

Importance of the periareolar approach in the augmentation of the ptotic breast

This is a retrospective review of 66 patients with grade II breast ptosis who underwent augmentation mammaplasty from January 1996 to January 2001. Of these 66 patients, 17 were augmented using a periareolar approach, and 49 were augmented using an inframammary approach. All patients had textured saline implants, and 64 of 66 patients had the implants placed in a submuscular position. Mean photographic follow-up was 4.8 months (range, 6 weeks-1 year). When compared with an inframammary approach in the presence of grade II ptosis, a periareolar approach results in improved fill of the lower pole of the breast, improved centralization of the nipple on the breast mound, and lessening or elimination of undesirable upper pole fullness.     

Y-Scar Vertical Mammaplasty for Treatment of Mild Macromastia with Pseudoptosis

Y-scar vertical mammaplasty is a technical modification of vertical scar breast reduction, which avoids superior areolar scarring. It has been previously shown to be particularly useful in young patients with mild macromastia and minimal or no ptosis. This case report presents a new indication for which to apply this technical approach. A 58-year-old patient presented with mild macromastia of mainly the inferior pole and pseudoptosis. Since there was no need to transpose the nipple, a Y-scar vertical mammaplasty was performed, removing tissue from the lower pole and preserving upper-pole fullness. Furthermore, superior areolar scarring was avoided. In conclusion, Y-scar vertical mammaplasty may find its use in other less commonly seen patient profiles such as this presented case of an older patient with slightly enlarged breasts and pseudoptosis.     

Mammaplasty with Inferior Pedicle Flap After Massive Weight Loss

Background  

After massive weight loss, one of the stigmas that afflict women is the remaining deformity of the breasts which become flaccid and ptotic, with an absent or flat upper pole. The authors propose the use of a well-established mammaplasty technique to fill the upper pole, reshape the breast cone, and correct ptosis with nipple–areola complex (NAC) repositioning.     

Mammaplasty: The “Super Flap” or the Superior Pedicle Extra Long Flap for Massive Breasts with Marked Ptosis or Gigantomastia

Background  Very large breasts associated with ptosis frequently present a challenge to the plastic surgeon in choosing the ideal procedure to obtain a satisfactory result. A free nipple graft, which for many represents the best option in these conditions, has many disadvantages. Methods  The author’s method of a superior pedicle flap allows for very long flaps, in some cases over 40 cm, and breast ptosis with the nipple at more than 55 cm from the suprasterna notch with preservation of the circulation to the nipple-areola complex. This procedure has been developed and modified from the French oblique method of Dufourmentel and Mouly converted to an inverted T, while the glandular resection is performed in a keel fashion behind the areola to house and give room for these very long flaps without undue compression on them and endangering the blood supply to the areola-nipple complex. Results  The method is described in detail, the early and late results presented, and advantages and disadvantages discussed. It has stood the test of time as it has been used regularly for more than 20 years and has become our standard method. Conclusion  The method presented is especially suitable for very large breasts with ptosis; however, excellent results are also achieved for all other degrees of ptosis, with very little modification in the procedure needed to suit different breast sizes and shapes. Most of the time we obtain a pleasing and attractive breast. This method rarely resulted in complications and never required a blood transfusion.     

Periareolar reduction mammaplasty utilizing the inferior dermal pedicle

The critical points which should not be overlooked when performing reduction mammaplasty are to minimize scar on the breast and to ensure a sufficient blood supply for the viability of the nipple–areolar complex. Periareolar reduction mammaplasty has been widely used because it left only one scar around the areola. However, with the typical periareolar reduction mammaplasty technique, it is difficult to remove a large amount of breast tissue and mobilize the remaining breast tissue. It may result in necrosis of the nipple–areolar complex in some cases. To overcome these limitations we combined the periareolar incision with the inferior dermal pedicle, which has a relatively good blood supply. This new technique was employed in 22 consecutive women (44 breasts) with hypertrophy and a varying degree of ptosis. Infiltration of a tumescent solution and liposuction were performed in all cases. After periareolar incision, dissection of the skin was performed, and the breast was elevated from the fascia of the pectoralis major muscle, leaving the inferior dermal pyramidal pedicle. An adequate amount of tissue was resected in the superior, medial, and lateral areas. After mastopexy, closure was done with a purse-string suture. The amount of tissue resected ranged from 180 to 1510 g per breast, and the mean was 466.1 g. The mean length of elevation of the nipple was 10.6 cm along the meridian of the breast. There were a few complications which needed revision operation: hematoma collection in one breast (2.3%), wound dehiscence in one breast (2.3%), and fat necrosis in one breast (2.3%). There was no necrosis of the nipple–areolar complex. With this new technique of periareolar reduction mammaplasty utilizing the inferior dermal pedicle, we were able to minimize the scar, preserve the nipple–areolar complex, and improve the motility of the breast tissue. But we also observed a flat or square appearance in the case of a large amount of resection in the patients with poor skin elasticity. This technique is safe and versatile and produces aesthetically acceptable results in selected patients.     

A False-Positive Fluorodeoxyglucose Positron Emission Tomography (FDG-PET) Imaging Result for a Patient After Augmentation Mammaplasty

Background  Various materials and methods have been used for augmentation mammaplasty since it was first performed in Japan in the late 1940s. Although augmentation mammaplasty is not associated with an increased risk of breast cancer, a number of studies have reported that breast implants, or subsequent changes around these foreign substances, can affect images made by mammography, CT, or MRI during breast cancer screening. A method that is increasingly being used to detect cancer is positron emission tomography (PET). Methods  To determine the effect of augmentation mammaplasty on PET imaging, we subjected ten women who had previously undergone augmentation mammaplasty to PET imaging as well as other imaging methods. We also measured tumor markers and performed pathologic studies. Results  The histologic analyses failed to detect any cases of malignancy. We assess the efficacy of PET for detecting breast cancer in women who had undergone augmentation mammaplasty and describe the features of the PET images of these women. Finally, we discuss future research objectives in relation to PET-based screening for breast cancer. Conclusion  It is important to identify an imaging methodology that improves the detection of breast cancer in patients with a previous mammaplasty. We show here that FDG-PET may improve breast cancer detection after mammaplasty.     

Fascial Suspension Mastopexy Combined with Augmentation Mammaplasty

Background  We have modified our technique of fascial suspension mastopexy to be used in combination with augmentation mammaplasty. This study aimed to assess the results of the combined procedure in our first consecutive 10 patients. The surgery aims to maximize long-term upper-pole fullness as well as optimal projection and shape in volume-depleted ptotic breasts. Methods  A retrospective case notes review was carried out, with details of patient demographics, indications, operative detail, and postoperative assessment recorded. In addition, patients were directly questioned to gain their opinion of the procedure. Results  Nineteen breasts were operated on in ten patients. On preoperative assessment two women (20%) had grade 3 ptosis and the rest had grade 2 (83%). The majority of women had had children and had breast-fed (70%). The mean follow-up period was 33 months (range = 4–55) and overall patient satisfaction was high despite six of the 10 patients undergoing minor scar revisions for dog-ears under local anesthetic and two undergoing implant exchange to correct minor asymmetries. There were no major postoperative complications in this series. All patients demonstrated good projection and upper-pole fullness at postoperative review. Conclusion  The combined technique of fascial suspension mastopexy and breast augmentation with implants is a safe and reliable method to correct ptosis in volume-depleted breasts. Patients should be counseled on the possible need for minor revisional procedures. Importantly, the technique achieves excellent upper-pole fullness and the projected and rejuvenated breast has an overall pleasing result.