Simultaneous breast augmentation and mastopexy

The results of combining breast augmentation and mastopexy are less predictable than those associated with mastopexy or augmentation mammoplasty alone. A method of breast skin envelope reduction is presented that allows the surgeon performing mastopexy to preview the final breast shape before committing to skin resection. This method, first described in 1978, has proven to be technically versatile and reproducible, and applicable not only to moderate (second degree) and severe (third degree) ptosis but also to simultaneous breast augmentation and mastopexy. For the combined procedures, the practical strategy proposed is first the implant placement through a periareolar incision, and a vertical transglandular incision, usually submusculofascial; second, restoring the gland anatomy by closing the muscularis and the vertical transglandular incision; third, skin envelope adjustment using the Tailor-Tack maneuver to accurately assure the best position of the nipple-areolar complex on the breast mound; fourth, skin incision, de-epithelialization and undermining; and finally, closure combining the the Purse-String maneuver with the vertical incision.     

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.     

The dermal overlap subareolar mastopexy: A preliminary report

Background: The major disadvantage of the circumareolar mastopexy is the risk of hypertrophic scarring and relapse or widening of the areola. Objective: The author describes a new technique that gives added support to the scar by means of a dermal overlap flap that is buried under the areola. Methods: A doughnut incision is made, with the size of the outer circle dependent on the amount of ptosis to be corrected. The areolar flap is elevated close to the nipple pedicle, a circumferential incision is made through the dermis between the pedicle and the outer incision, and the dermal edge is elevated. After the mastopexy, closure is performed with nonabsorbable purse-string sutures. Results: Initial results in a series of 34 cases have been encouraging, with no loss of nipple sensation and with less scarring and more natural nipple projection than occurs in conventional doughnut mastopexy procedures. Conclusions: This technique can be used to reduce scarring in procedures such as mastopexy, breast reduction, and tubular breast correction. (Aesthetic Surg J 2001;21:423-427.)     

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.     

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.     

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.     

Extended Crescent Mastopexy with Augmentation

Problems with periareola or circumareolar mastopexy procedures include areola spreading, hypertrophic scar, and recurrence of the ptosis largely because of tension on the closure. To minimize this tension associated with a conventional crescent mastopexy procedure, the authors modified the operation by excising parenchyma with the crescent of skin as well as two small triangles of parenchyma on either side of the areola. Implant augmentation was performed at the same time. The described operation is indicated for patients who have a small to moderate amount of ptosis. The best candidate is the patient whose areola–inframammary distance is not excessive. Nine such patients received this “extended crescent mastopexy with augmentation” and were followed for up to 3 years. Areola spreading and hypertrophic scar were kept to a minimum. Although not the final answer for ptosis patients, the extended crescent mastopexy with augmentation has been a step in the right direction.     

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.     

Revision augmentation mastopexy: indications, operations, and outcomes

In the absence of any published information on the indications, frequency, and outcomes of revision augmentation/mastopexy, an 8-year retrospective review was undertaken of all patients undergoing revision of a previous augmentation/mastopexy in the senior author's practice. The data collected included original implant type, location and mastopexy type, indication for revision, interval from original surgery, new implant type, location, and associated corrective surgical procedures. A simultaneous review was also performed of all primary augmentation/mastopexies done during the same period.Twenty patients underwent revision of 34 previously performed augmentation/mastopexies. Five patients underwent revisions of a prior revision. Fourteen were bilateral, while 6 were unilateral, for a total of 34 breasts. Forty patients underwent primary augmentation/mastopexy during the same period. Among the revisions, 10 implants were originally subglandular, while 24 were either partly or totally submuscular. Twelve of the previous mastopexies were periareolar, 2 were vertical, and 20 were of the inverted T-type. The indications for revision included capsular contracture in 11 of 20 (55%) patients, nipple ptosis in 11 of 20 (55%) patients, implant malposition in 7 of 20 (35%) patients, dissatisfaction with implant size in 6 of 20 (30%) patients, poor scar in 5 of 20 (25%) patients, breast ptosis in 4 of 20 (20%) patients, nipple malposition in 2 of 20 (10%) patients, and patient preference in 1 of 20 (5%) patients. Most patients had 2 or more indications for revision. The average duration to revision was 7 years. In 13 of 20 (65%) patients, no change in implant type was made. The remainder had exchanges to a different type. In 12 of 20 (60%) patients, no change in implant location was made, whereas 8 of 20 (40%) patients had a change to the subpectoral or dual plane position. In 18 of 20 (90%) patients, the revision included the same type of mastopexy, while in 2 of 20 (10%) patients, the type of mastopexy was changed. Corrective surgical procedures performed included repeat mastopexy, capsulectomy, change of implant type, change of implant location, change of implant size, capsulotomy, capsulorrhaphy, and scar revision. To date, all of the patients are satisfied with their appearance. Follow-up ranged from 2 months to 4 years.Revision augmentation mastopexy is not an uncommon procedure, occurring half as often as primary augmentation/mastopexy in our series. There were 8 common indications for revision, with capsular contracture and recurrent ptosis being the most common. Eight surgical procedures, in various combinations, were performed during revision, with repeat mastopexy being the most common.     

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     

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。     

Clinical Series of Oncoplastic Mastopexy to Optimize Cosmesis of Large-Volume Resections for Breast Conservation

Background

Oncoplastic mastopexy has been popularized as a method to hide the cosmetic effects of central or large-volume resections associated with breast conservation surgery for breast cancer.

Materials and Methods

This review was undertaken to study the uses and limitations of these techniques in providing adequate breast conservation lumpectomy for breast cancer of any stage in a single surgeon’s practice. A review of breast cancer cases March 2004 through December 2009 were analyzed for the use of oncoplastic reconstruction in breast conservation surgery.

Results

A total of 167 patients had lumpectomies during this period associated with oncoplastic mastopexy reconstruction. The average age was 55.6 years with a range of 33–85 years. Stage 0 breast cancer accounted for 33 cases (19.8%), and 134 cases were invasive cancers stages 1–3 (stage 1, 34.1%; stage 2, 30.6%; and stage 3, 15.6%). The most common oncoplastic techniques used were, in order of frequency: batwing mastopexy, parallelogram mastopexy, and Modified Wise pattern mastopexy. Positive or close margins (≤2 mm) were present in 37 of 167 cases (22%). Positive margins were most associated with higher stage, positive nodes, positive lymphovascular invasion (LVI), use of neoadjuvant chemotherapy, and larger initial T stage, positive estrogen receptor (ER), and younger age. Of these higher stage, node positive, and use of neoadjuvant chemotherapy were statistically significant in this small series (P values = 0.034, 0.016, and 0.022, respectively). Ki-67 and HER2 status were not associated with positive margins. Positive margins were manageable by local re-excision of a solitary face of the prior resection wall in more than 2/3 of cases to achieve negative pathologic margins. Only 11 of 167 required mastectomy because of failure to achieve adequate margins for oncologic control.

Conclusions

Oncoplastic mastopexy allows the surgeon to address large tumors or tumors in cosmetically difficult sites adequately for breast conservation. Careful margin marking and re-excision of close or positive margins is still often feasible to achieve adequate negative margin with acceptable cosmesis in spite of the large initial volumes of resection.     

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.     

Pyoderma gangrenosum: a challenging complication of bilateral mastopexy

A case of pyoderma gangrenosum progressively developing after bilateral mastopexy at the surgical site is described. The described case was successfully treated with corticosteroids, the application of the dermal regeneration template Integra and autologous skin grafts. This approach was able to save the patient's life and to generate a high-quality aesthetical outcome. The article reported the case, reviewed the literature of pyoderma gangrenosum related to mastopexy or augmentation mammoplasty and discussed the use of a dermal regeneration template to optimise aesthetical results after reconstructive surgery.     

Vertical Mammaplasty: A Personal Approach

We have been using the vertical mammaplasty technique with personal adjustments for reduction mammaplasty and glandular resection since 1989. There were 63 cases of aesthetic reduction mammaplasty and mastopexy and 38 cases of reduction mammaplasty and mastopexy contralateral to breast reconstruction with implants and/or autologous tissues performed during the period from 1989 to 1993. The aim of this work is to discuss the complications, long-term results, and limitations to this technique.     

Does the reductive mastopexy with implant approach prevent the late bottoming out?

Background

After breast surgery, the late upward rotation of the nipple–areola complex and the increased of the fullness at the lower pole of the breast have been defined as a Bottoming out. Although several studies have focused on the safety and complication rate of the one-stage augmentation/mastopexy, there is no clear recommendation how to prevent the late complication of “bottoming out”.

Methods

A retrospective review was conducted of 48 consecutive patients who underwent one-stage mastopexy/augmentation using the reductive approach. Data collected included the following: patient's characteristics implant information, operative technique and postoperative results. Complication and revision rates were assessed to determine the efficacy of the reductive mastopexy/augmentation.

Results

All patients (N?=?48) were available for follow-up, an average 18 months postoperatively. Overall complication rate was 14.5%. No severe complications were recorded. The most common complication was wound separation (2), followed by capsular contracture (2), and bottoming out (1). Seven patients (14.5%) underwent some form of revision surgery following the one-stage procedure. The revision rate due to bottoming out was 2.2%.

Conclusions

When performing the one-stage augmentation/mastopexy procedure, using the reductive mastopexy approach does effectively reduce the internal tension from the lower pole of the breast and helps to prevent the occurrence of bottoming out. Level of Evidence: Level IV, therapeutic study     

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.     

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.