Improving the Longevity and Results of Mastopexy and Breast Reduction Procedures: Reconstructing an Internal Breast Support System with Biocompatible Mesh to Replace the Supporting Function of the Ligamentous Suspension

Background

The reasons for recurrent ptosis in mastopexy and breast reduction procedures are twofold. First, available surgical techniques do not reconstruct the normal breast anatomy responsible for maintaining breast shape. Second, in many instances the techniques rely on atrophied tissue to provide long-term support. The discovery in 1997 of the ligamentous suspension (the supporting system of the breast) gave rise to the concept that reconstruction of this anatomical structure was needed to ensure a sustained postoperative result. Applying the latest knowledge regarding the structural and vascular anatomy of the breast in the surgical technique and utilizing material other than atrophied breast tissue enabled us to prevent the recurrence of breast ptosis.

Methods

A surgical technique was developed to replace the supportive function of a failed ligamentous suspension in 112 patients with ptotic breasts. This was done by reconstructing an internal breast-supporting system (IBSS) with biocompatible mesh.

Results

Satisfactory breast shape, nipple projection, and upper breast fullness was obtained with this technique in mastopexy patients with moderate-sized ptotic breasts. In patients with larger breasts good results were obtained with a simultaneous breast reduction. The longest follow-up is 6?years 3?months.

Conclusions

With this technique recurrent breast ptosis can be prevented in mastopexy and breast reduction procedures. The results are such that it eliminates the need for silicone prostheses to obtain satisfactory upper-breast fullness. The surgical technique is especially indicated in patients with skin of poor quality or patients with high expectations.     

Central core reduction mammoplasties and Marlex suspension of breast tissue

The author describes a technique for central core reduction mammoplasty with the same technique being utilized for a mastopexy. By transposition of the nipple areolar complex, the nerve supply as well as the vascular supply is maintained on an inferiorly based dermal pedicle. This technique does not require the recall of a multitude of points or locations or other maneuvers necessary to do the markings to obtain a symmetric, aesthetically pleasing reduction. The author has also developed a technique for the use of Marlex Mesh to support the remaining breast tissue and, by attaching the mesh to the area of the second rib, the support of the breast tissue is converted from cutaneous origin to skeletal origin, giving an internal support of breast tissue and preventing subsequent early ptosis and loss in fullness of the upper portion of the breast. The mesh has been used in 43 patients over the past two years with no serious 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。     

Mastopexy with autologous augmentation after massive weight loss: the intercostal artery perforator (ICAP) flap

The reconstruction of breast and upper-body deformities in massive weight loss (MWL) patients presents specific challenges to the plastic surgeon. In addition to significant breast ptosis and loss of breast volume, bariatric patients also have excessive lateral axillary and posterior truncal tissue that may require dermolipectomy for correction. A wise-pattern mastopexy was designed with a pedicled fasciocutaneous flap based on the intercostal artery perforators (ICAP) to correct breast ptosis, to restore breast volume, and to eliminate redundant upper truncal tissue. Five MWL patients underwent mastopexy with ICAP flap augmentation. All patients had stable and esthetically pleasing results 1, 3, and 6 months postoperatively. There were no complications of infection, wound dehiscence, seroma, or hematoma. Furthermore, there was no evidence of flap loss or tissue necrosis. Mastopexy with autologous augmentation using the ICAP flap was found to be a reliable method of breast reconstruction in the MWL patient.     

Periareolar augmentation mastopexy: A new approach dealing with the cases as tuberous breasts

Background:Periareolar augmentation mastopexy is one of the most demanded operations at Plastic Surgery clinics. Nevertheless, it is one of the leads of malpractice claims in United States caused by the high patient expectations and the standard surgical techniques which may result in common complications. The aim of this report is to present a new surgical approach to solve these complications.Methods:After establishing a working hypothesis, we performed a revision study of our patients and we came to the following conclusion: in order to perform a periareolar mastopexy for ptosis correction, breast has to be tuberous at any level and to have abnormally short inferior pole. These findings may explain the main complications from periareolar augmentation mastopexy with the standard surgical techniques. Consequently, we started a prospective observational study including 56 patients following a new surgical technique which deals the cases as tuberous breasts.Results:During three years, fifty-six periareolar mastopexies were performed with this new surgical approach with one year follow-up. No major complications were observed and 40 of the patients (71%) described the results as very positive.Conclusion:“If a periareolar mastopexy can be performed, then it must be a tuberous breast”. According to this, a new surgical technique for periareolar augmentation mastopexy has been developed obtaining an improvement in our surgical results and achieving a totally different view on this pathology, which has not been reported in literature yet.KEY WORDS: Aesthetic breast surgery, anomalies, breast base, periareolar mastopexy, ptosis, tuberous breast     

Improving shape and symmetry in mastopexy with autologous or cadaveric dermal slings

Mastopexy and reduction mammaplasty reshape breast parenchyma and restore youthful contour in women with ptotic breasts. However, recurrent ptosis and breast base widening are common. We have been using internal autologous or cadaveric (AlloDerm) dermal slings to circumferentially support and shape the breasts for symmetry or rejuvenation. Ten patients underwent unilateral mastopexy (3), unilateral reduction-mastopexy (1), bilateral mastopexy (5), or bilateral reduction-mastopexy (1) with an internal dermal sling to correct breast reconstruction asymmetry (2), congenital asymmetry (2), or acquired ptosis (6). Three of 6 patients acquired breast ptosis after massive weight loss. Autologous dermis was used in 5 patients, and 5 patients were reconstructed with AlloDerm. Patients have maintained projection and breast base width after 6 months to 3 years. In conclusion, internal dermal slings improve shape, breast projection, and base width in select patients undergoing mastopexy. An algorithm based on quantity and quality of native skin is provided.     

A classification and algorithm for treatment of breast ptosis

Background: The Regnault classification of breast ptosis is insufficient for determining surgical strategies for different stages of ptosis. Objective: A new clinical classification of breast ptosis is proposed that allows greater precision in the development of an appropriate surgical plan. Methods: Breast ptosis is classified in 1-cm stages, beginning with stage A at 2 cm above the inframammary crease and continuing through stage E at 2 cm below the inframammary crease, with any level of ptosis beyond stage E defined as stage F. Increments of 1 cm were chosen because each level predicts a different amount of skin excision necessary to elevate the nipple-areolar complex to an ideal aesthetic level. An algorithm is provided for defining options for surgical management of the ptotic breast with and without augmentation and for the previously augmented breast. Results: Seventy-three cases of breast ptosis were treated with augmentation mammaplasty, simultaneous areolar mastopexy breast augmentation, Wise mastopexy breast augmentation, and other procedures following the proposed classification system and treatment algorithm. Conclusions: The new system for staging of breast ptosis is simple and easy to remember and can assist in the planning and evaluation of surgery. (Aesthetic Surg J 2002;22:355-363.)     

Mastopexy for breast ptosis: Utility outcomes of population preferences

BACKGROUND:

Breast ptosis can occur with aging, and after weight loss and breastfeeding. Mastopexy is a procedure used to modify the size, contour and elevation of sagging breasts without changing breast volume. To gain more knowledge on the health burden of living with breast ptosis requiring mastectomy, validated measures can be used to compare it with other health states.

OBJECTIVE:

To quantify the health state utility assessment of individuals living with breast ptosis who could benefit from a mastopexy procedure; and to determine whether utility scores vary according to participant demographics.

METHODS:

Utility assessments using a visual analogue scale (VAS), time trade-off (TTO) and standard gamble (SG) methods were used to obtain utility scores for breast ptosis, monocular blindness and binocular blindness from a sample of the general population and medical students. Linear regression and the Student’s t test were used for statistical analysis; P<0.05 was considered to be statistically significant.

RESULTS:

Mean (± SD) measures for breast ptosis in the 107 volunteers (VAS: 0.80±0.14; TTO: 0.87±0.18; SG: 0.90±0.14) were significantly different (P<0.0001) from the corresponding measures for monocular blindness and binocular blindness. When compared with a sample of the general population, having a medical education demonstrated a statistically significant difference in being less likely to trade years of life and less likely to gamble risk of a procedure such as a mastopexy. Race and sex were not statistically significant independent predictors of risk acceptance.

DISCUSSION:

For the first time, the burden of living with breast ptosis requiring surgical intervention was determined using validated metrics (ie, VAS, TTO and SG). The health burden of living with breast ptosis was found to be comparable with that of breast hypertrophy, unilateral mastectomy, bilateral mastectomy, and cleft lip and palate. Furthermore, breast ptosis was considered to be closer to ‘perfect health’ than monocular blindness, binocular blindness, facial disfigurement requiring face transplantation surgery, unilateral facial paralysis and severe lower extremity lymphedema.

CONCLUSIONS:

Quantifying the health burden of living with breast ptosis requiring mastopexy indicated that is comparable with other breast-related conditions (breast hypertrophy and bilateral mastectomy). Numerical values have been assigned to this health state (VAS: 0.80±0.14; TTO: 0.87±0.18; and SG: 0.90±0.14), which can be used to form comparisons with the health burden of living with other disease states.     

Periareolar Mastopexy with FortaPerm

Background  

Recurrent ptosis is a common sequel of mastopexy. The use of mesh as an adjunct to the double-skin technique was developed to reduce the incidence of recurrent ptosis. The optimal mesh needs to strike the right balance between persistence, inflammation, biocompatibility, and incorporation without interfering with mammography or presenting a long-term infection risk. This study investigated the ability of a biologic tissue matrix, FortaPerm, to achieve these goals.     

Combined superior crescentic total glandular augmentation mastopexy: report of 37 cases

Methods of periareolar, donut, or crescentic patterns for augmentation mastopexy in mild to moderate ptosis cases are minimally invasive (short scar) options. In this article, we report a modified version of the classical crescentic technique of augmentation mastopexy, namely, “superior crescentic total glandular augmentation mastopexy”. Thirty-seven patients with (a) breasts having mild to moderate ptosis (Regnault grades I–II), (b) breasts requiring less than 3 cm of nipple–areola elevation, and (c) mild skin elasticity were included in the study. During surgery, the mean size of 290 cc of silicon gel-filled implants were placed. The mean follow-up was 39 months ranging from 6 and 58 months. None of the patients had disastrous complications such as skin or nipple–areola necrosis. Poor scar healing and areolar asymmetry were the main problems encountered during follow-up. Ptosis recurrence (n = 1), and capsular contracture (n = 1) were the main reasons for revision surgery (5.4%). Five patients were re-operated on due to complications and implant change requirements (13.5% , total revisions). Mean suprasternal notch–nipple distance was recorded as 20.8 cm (19.3–22.4 cm) postoperatively. After an average time of 39 months, this distance was found to be 21.2 cm (20.1–23.2 cm) (the case with the recurrent ptosis was excluded). Superior crescentic total glandular augmentation mastopexy has yielded satisfactory results in patients with mild to moderate breast ptosis; therefore, it seems to be a valuable option in terms of minimally invasive augmentation mastopexy techniques.     

The modified hexagonal technique for reduction mammoplasty and mastopexy

In 1982, we described the hexagonal technique for correction of breast ptosis or moderate degree of breast hypertrophy. Since then we have modified the technique mainly to be able to correct the severe as well as the moderate degree of breast hypertrophy. This technique has provided the versatility in achieving good results in various degrees of reduction mammoplasty and mastopexy.Presented in part to the Egyptian Society of Plastic and Reconstructive Surgeons in Cairo, Egypt, March, 1984     

Pectoris major muscle flap in mammaplasty

Due to the late postoperative permanent ptosis recurrence in breast reduction and/or mastopexy, the senior author has introduced a new surgical technique using the inferior third of the pectoralis major muscle which constructed and fashioned according to the anatomo-histological variations. Fixation of this muscle flap to the inferior pole of the mammary gland will avoid any future breast ptosis. Personal experience with 51 consecutive cases of breast reduction and/or mastopexy operated between March 1994 and March 1996 is reported. The procedure is illustrated in details; the main indications, late results, limitations and possible early and late complications are studied and discussed.     

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.     

A new periareolar mammaplasty: the "round block" technique

The "round block" acts as a keystone supporting the mammary cone. The keystone lies in the dermodermic, glandulo-glandular, and glandulo-musculoperiosteal unions fixed definitively with nonresorbable suture, by a crisscross mastopexy, and by a circular nonresorbable suture of woven nylon included in the periareolar circular dermo-dermic scar block. This technique can be used in numerous types of breast surgery: In cases of ptosis or hypertrophy, it allows the scar to go up to the periareolar circle which is in itself generally inconspicuous. In cases of hypotrophy, the use of the round block technique permits easy access for insertion of the prosthesis as it simultaneously corrects ptosis. In cases of tumoral excision, the round block produces a discreet scar and a more regular breast contour. In all types of mammoplasty, the main goal is to limit the scar. The scar in the submammary fold is visible, particularly when one is lying down. The ideal result is confining the scar to the periarolar area.     

Triangle Resection with Crescent Mastopexy: An Oncoplastic Breast Surgical Technique for Managing Inferior Pole Lesions

Resection of inferior pole breast cancers commonly produces inferior cosmetic results, particularly when resection of skin is required. The triangle resection with mastopexy is one of several oncoplastic breast surgical techniques that enable resection of inferior pole lesions with preservation if not improvement of breast cosmesis. This procedure may be combined with unilateral or bilateral mastopexy to further improve breast cosmesis in patients with mild to moderate ptosis.     

A new technique of internal suture mastopexy for mild to moderate breast ptosis

BACKGROUND:

Current mastopexy techniques rely on incisions on the breast to correct ptosis. Trading a ptotic breast for a visibly scarred breast can be a difficult choice.

OBJECTIVE AND METHODS:

A technique of internal suture mastopexy that consists of plicating sutures placed in the superficial fascia of the breast from the deep surface is presented. The procedure leaves no scar on the breast and may be safer than other techniques when combining mastopexy with augmentation.

RESULTS:

The senior author has performed this procedure on over 120 patients, with a mean follow-up of two years. Patients and the surgeon have expressed satisfaction with the procedure.

CONCLUSION:

Based on this experience with over 120 patients, the authors believe that internal suture mastopexy is an effective alternative in selected patients.     

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.     

腺体外侧蒂皮肤双环切口乳房塑形悬吊术

目的探讨腺体外侧蒂皮肤双环切口乳房塑形悬吊术,在矫正乳房下垂中的应用。方法自2003年以来,应用外侧蒂双环切口乳房塑形悬吊术,矫正乳房下垂患者30例,“楔”型切除乳房下极部分腺体组织,腺体瓣相对旋转缝合固定于胸肌筋膜,保留部分腺体于内上方皮瓣,乳房上极悬吊至第2、3肋软骨膜。结果术后随访患者1~3个月,均获得满意效果。结论外侧蒂双环切口乳房塑形悬吊术,可以有效地塑形悬吊乳房,术后切口隐蔽,乳房上极饱满,是矫正乳房下垂的一种理想选择。     

The Application of Mesh Support in Periareolar Breast Surgery: Clinical and Mammographic Evaluation

Background Numerous techniques have been described for the treatment of breast hypertrophy and ptosis. Unfortunately, recurrent ptosis after mammaplasty can occur regardless of the technique used. To avoid this problem, different kinds of supporting devices have been described with variable rates of success. However, the true implications of incorporating prosthetic materials into breast surgery have never been clarified. Therefore, surgeons have traditionally been reluctant to apply any kind of prosthetic material to the breast, fearing inflammation, an unfavorable aesthetic outcome, palpable or visible deformities, and interference with the mammographic evaluation of breast cancer. This study analyzed the aesthetic, clinical, and mammographic implications of using mesh as a supportive device in periareolar breast surgery.Methods For this study, 18 patients (mean age, 42 years) with breast hypertrophy, ptosis, or both were managed with the double-skin periareolar mammaplasty technique, with placement of mixed (60% Polyglactine and 40% polyester) mesh. Clinical assessment was performed by three breast surgeons actively working on cancer surveillance who knew that the patients had experienced mesh application. After a mean follow-up period of 30 months, a standard mammogram was performed for each patient and analyzed by both the surgeons and an expert radiologist. The evaluated factors were hyperemia, calcifications, contour irregularities, capsular contraction, thickening or widening of the scar with extrusion of the mesh, and any palpable or hardened areas.Results According to the authors clinical observations, there were no mesh-related abnormalities in the breast; the mesh was not palpable after the operation; and there was no recurrent ptosis. In terms of mammographic imaging, the mesh was visible as a very fine line in the periphery of the breasts parenchyma (measuring 0.2 mm on the lateral views) in three patients (17%). The mesh did not interfere with the visualization and analysis of the breasts parenchyma. In seven patients (39%), benign localized microcalcifications were detected in the breast and no further investigation was performed. In two patients (11%), grouped calcifications were detected and biopsied, with histopathologic analysis demonstrating epithelial hyperplasia with atypia. In two patients (11%), nodules smaller than 1 cm were detected and biopsied, with histopathologic analysis demonstrating a fibroadenoma in one patient and an invasive ductal carcinoma in the other.Conclusions The use of mesh support in breast surgery can enhance the aesthetic results without inducing visible or palpable deformities or mammographic abnormalities. In terms of surveillance mammograms, the presence of the mesh did not interfere with the diagnosis and treatment of minute lesions such as calcifications and small nodules