Calobrace, M. Bradley M.D.; Herdt, Donald R. B.S.; Cothron, Kyle J. M.D.
The simultaneous augmentation/mastopexy entails the inherent challenge of expanding breast volume and concurrently reducing the skin envelope. The operation indeed holds special challenges nonconcomitant with the individual procedures alone. It has been suggested that performing the simultaneous procedure introduces a significant degree of added risk and uncertainty in the prediction of postoperative results,1–6 with its use even being discouraged by some.3 However, there are admittedly many advantages to performing these procedures simultaneously, the most obvious being the avoidance of a second operation in many patients. This has obvious advantages for the patient: it is economically less burdensome, reduces risks inherent in an additional operation, and avoids disappointment in the result in the interim between the two operations. In our experience, patients overwhelmingly prefer to undergo augmentation and mastopexy concurrently rather than have a staged procedure. Therefore, the simultaneous augmentation/mastopexy has routinely been used in our practice as the preferred approach for breast ptosis. We have found the combined procedure worthwhile, considering patient safety and efficacy, as in the experience reported by others.7–12 The objective of this study was to review our 5-year experience of consecutive simultaneous augmentation mastopexies, evaluating patient selection, surgical approach, and associated complication and reoperation rates.
PATIENTS AND METHODS
A 5-year history (January of 2005 to December of 2009) of simultaneous augmentation/mastopexy operations was studied retrospectively. All operations were performed by the senior author of this study (M.B.C.). Data were collected for 430 patients who underwent mastopexy surgery, including 332 patients who underwent simultaneous augmentation mastopexies. This study focused on the 332 simultaneous augmentation/mastopexy patients, with the 98 mastopexy-only cases examined for comparison. Patient demographics, preoperative assessment, and operative approach were evaluated and correlated against rates of complications and reoperations. The patient demographics measured included age, sex, height, preoperative weight, smoking status, history of previous breast surgery, and gravida status. Smokers consented to discontinue smoking a minimum of 2 weeks before surgery, although serum nicotine levels were not obtained for verification of compliance. Mastopexy type was documented for each breast, as were implant specifications including fill, shape, volume, profile, and pocket position. All additional breast procedures concurrent with augmentation/mastopexy surgery were noted (e.g., implant removal, pocket exchange). The patients who underwent mastopexy alone during the same period were primarily compared for complication and reoperation rates. Statistical significance was evaluated using Fisher's exact test.
Complications were noted as unilateral or bilateral and categorized as tissue-related or implant-related. The definition of implant-related complications included Baker grade III/IV capsular contracture, implant malposition, periprosthetic seroma, implant failure, infection, and implant-related hematoma. Tissue-related complications encountered included partial necrosis, recurrent ptosis, areolar asymmetry, poor scarring, breast asymmetry, and mastopexy-related hematoma. The categorization of the hematoma was determined by its location; a hematoma within the breast implant pocket was categorized as implant-related and a hematoma isolated to the mastopexy flap without blood within the implant pocket was considered tissue-related. Patients were categorized as having recurrent ptosis for either stretch deformities of the lower pole or ptosis of the breast tissue over the implant (i.e., Snoopy's nose deformity). Partial necrosis included all cases of ischemia-induced necrosis of breast flap or nipple-areola complex irrespective of whether a surgical reoperation was required.
Reoperations were categorized as implant-related or tissue-related as a function of the complication. The only additional reoperations included that were not a result of a complication were for implant size change. For cases requiring multiple reoperations for the same complication, only the first reoperation was documented, as has been previously described.13,14
Although the majority or mastopexies were performed concurrently with the augmentation (332 of 430), mastopexy alone (98 of 430), with or without a staged augmentation, was selected for some patients. In our practice, patients with obesity, large pendulous breasts requiring significant nipple-areola complex elevation (>6 cm) or significant breast volume reduction, and/or unwillingness to completely stop smoking for a minimum of 2 weeks before surgery were all less likely to be selected for a combined procedure. In patients considered appropriate for a simultaneous procedure, mastopexy approach and implant selection were an integral part of preoperative planning. Planning the exact approach can be somewhat uncertain, as the spectrum of breast ptosis is a continuum. Therefore, the mastopexy approach was not determined completely preoperatively but rather planned presumptively based on the following: the Regnault level of ptosis15 with respect to the location of the nipple-areola complex in relationship to the inframammary fold, the location of the nipple-areola complex in relationship to the overall breast mound, the amount of breast overhanging the inframammary fold, and ultimately the vertical excess present, measured as the distance from the new nipple position to the inframammary fold under stretch (Fig. 1).
Patients with a need for nipple-areola complex repositioning or reshaping and whose need for breast lifting was minimal were selected for a circumareolar mastopexy. These were often patients primarily interested in augmentation, and the lift was considered necessary to achieve an optimal outcome. This included patients with tuberous breasts and grade 1 or 2 ptosis with minimal breast overhanging the fold (<3 cm). Patients with more severe ptosis (grade 2 or 3) and/or significant overhang (3 to 4 cm or greater) required a more significant lift through a vertical (with or without a short horizontal scar) or inverted-T approach. Although the final determination was made intraoperatively, preoperative assessment was critical to patient counseling and surgical planning. A patient with significant vertical breast skin excess of greater than 8 to 10 cm was considered more likely to need a greater circumareolar excision to remove vertical excess or a horizontal ellipse of skin removed as part of the vertical approach. The greater the vertical excess, the greater the elliptical resection and resultant length of the inframammary scar.
Implant selection was based on dimensional characteristics of the chest wall and soft-tissue envelope, taking into consideration the patient's desires as well. In patients requiring primarily an augmentation, implant selection was performed as with any standard breast augmentation. In a patient who primarily required a breast lift, implants were often selected to achieve a desired shape or improvement in upper pole volume with less adherence to strict dimensional considerations. In our experience and as recently documented by others,16 currently existing mastopexy-alone techniques have fallen short in their ability to effectively increase breast projection or upper pole volume. We have observed that the placement of an implant with the mastopexy more predictably produced the desired improvement in breast shape. Implant selection required factoring in the changes in breast width resulting from a significant mastopexy and the anticipated tolerance of the ptotic skin envelope for the desired implant. This was often the smallest implant that could effectively achieve the desired breast shape.
Preoperative Markings and Surgical Technique
Preoperative markings were performed with the patient in the upright position. The inframammary fold, midline, and breast median were initially drawn. The proposed new nipple position was marked by simulating the mastopexy and locating the ideal position, taking into consideration its location on the breast mound and relationship to the inframammary fold.
In the circumareolar approach, the new areola superior border was marked 2 cm above the new planned nipple position and the inferior areola location was marked approximately 6 to 8 cm above the fold. An oval was drawn from the two points around the areola to create the desired shape. The areola was marked from 38 to 42 mm in diameter and incised. The augmentation was performed through an inferior areola incision with implant placement in a subglandular or dual-plane subpectoral pocket. The excess circumareolar skin was deepithelialized and the outer dermis was released with undermining of the breast flaps for a few centimeters. The breast tissue was closed as a deep separate layer to skin closure and a 3-0 Gore-Tex (W. L. Gore & Associates, Flagstaff, Ariz.) purse-string suture. Ethibond (Ethicon, Inc., Somerville, N.J.) was used in all cases to minimize circumareolar spreading (Fig. 2).
With vertical and inverted-T mastopexies, the augmentation was performed first through an incision extending vertically from the nipple-areola complex to 2 cm above the inframammary fold so that the implant could be placed in the desired pocket (Fig. 3). Pocket decision was determined based on soft-tissue coverage and/or preexisting pocket location in secondary cases, with the preferred pocket being dual-plane submuscular in the majority of cases. Tailor tacking, a critical technique in our combined procedures, was performed starting at the planned new nipple position and extending inferiorly toward the fold, creating the desired breast shape and lift. If the vertical limb from nipple to fold was longer than 8 to 10 cm, the vertical excess was reduced through expanding the circumareolar excision or performing an elliptical excision along the fold. Thus, the final skin pattern for excision was determined only after the implant was in place to ensure optimal tightening and symmetry. A superior dermal pedicle was used in all cases, maintaining dermal attachment in the superior half of the areola. The circumareolar skin was deepithelialized and all remaining skin in the vertical and inferior poles was excised. Breast flaps were undermined and mobilized sufficiently to allow closure with minimal tension. The breast tissue was closed over the implant on the deep surface of the vertical breast parenchyma just superficial to the implant. Any significant breast tissue present in the lower pole overlying this closure was routinely debulked to reduce tension on closure and potentially reduce pseudoptosis postoperatively. The resection of lower pole breast tissue when indicated was possible through the consistent use of a superior dermal pedicle. Skin was closed in multiple layers (Fig. 3).
The follow-up period for this study was 1 to 6 years, with a mean follow-up of 1.5 years. Of the 332 patients undergoing simultaneous breast augmentation/mastopexy surgery, 235 were primary breast cases and 97 were secondary breast cases. The average patient age was 37 years (range, 16 to 72 years). The average body mass index of patients was 24.7 (range, 15.6 to 43) (Tables 1 and 2). All patients in this study were women, with 81 percent of patients (269 of 332) being postpartum. Smokers composed 18 percent of patients (60 of 332) undergoing simultaneous surgery.
Of the 332 augmentation/mastopexy cases, bilateral mastopexy surgery was performed on 322 patients, with 10 patients undergoing mastopexy surgery unilaterally. As for the mastopexy approach, 40 percent were inverted-T, 40 percent were vertical (with or without a short inframammary incision), and 20 percent were circumareolar (Table 2).
Bilateral breast augmentations were performed in 326 patients, with six being unilateral. The implant selection was 73 percent (241 of 332) silicone and 27 percent saline (91 of 332), with an average implant fill volume of 392 cc. The use of silicone-filled implants increased progressively throughout the course of the study, from 61 percent of total implants used in 2005 to 85 percent in 2009. Implant profiles were 48 percent moderate-plus, 34 percent moderate, and 18 percent high. One patient received an anatomical form-stable cohesive gel implant. Pockets used for implant placement included 84 percent (278 of 332) dual-plane submuscular pocket, 12 percent (41 of 332) subglandular, and 4 percent (13 of 332) subfascial. Subglandular placement was used more often in secondary cases (25.8 percent, 25 of 97) as compared with primary cases (6.8 percent, 16 of 235), likely reflecting preexisting pocket location (Table 1). In primary cases, subglandular implant placement declined over the course of this study, with 11 of 16 cases in 2005 and none in 2009.
There were no deaths, pulmonary embolisms, deep venous thromboses, or major tissue losses of any type resultant from surgery. There were two implant infections resulting in implant extrusion. The overall complication rate for simultaneous augmentation/mastopexy surgery was 22.9 percent (76 of 332). Secondary cases displayed a complication rate of 28.9 percent (28 of 97), whereas the complication rate for primary cases was 20.4 percent (48 of 235). The majority of complications were tissue-related, 15.1 percent (50 of 332) as compared with implant-related, 7.8 percent (26 of 332). The three most common complications were, in descending order, capsular contracture (13 of 332), poor scarring (11 of 332), and recurrent ptosis (11 of 332) (Table 3). There was no apparent correlation between complication rates and smoking status, body mass index, pocket location, or mastopexy approach.
The overall reoperation rate was 23.2 percent (77 of 332) for our simultaneous augmentation/mastopexy cases, with 20.0 percent (47 of 235) for primary cases and 30.9 percent (30 of 97) for secondary cases. Secondary patients were associated with a statistically significant higher rate of reoperation (p = 0.0447). The most common indications for reoperation were capsular contracture (11 of 332), poor scarring (11 of 332), and recurrent ptosis (11 of 332). Of the 23.2 percent overall reoperation rate, tissue-related indications constituted 13.3 percent (44 of 332) and implant-related indications constituted 9.9 percent (33 of 332) (Table 4 and Fig. 4). There was no apparent correlation between reoperation rates and smoking status, body mass index, pocket location, or mastopexy approach.
Of the 98 mastopexy-only cases evaluated for comparison, 75 were primary breast cases and 23 were secondary cases. The average body mass index for members of this group was statistically higher at 26.5 as compared with 24.1 for the simultaneous group (Table 2). This most likely represents a selection bias against performing the simultaneous procedure on overweight patients. There was also a higher prevalence of inverted-T incisions used for mastopexy alone versus the simultaneous group (81 percent versus 40 percent) (Table 2), reflecting a greater need to excise lower pole volume. The complication and reoperation rates for mastopexy alone were 12.2 percent (12 of 98) and 10.2 percent (10 of 98), respectively.
The combination of a mastopexy performed simultaneously with a breast augmentation is not a novel concept and was initially described by Gonzalez-Ulloa17 and shortly thereafter by Regnault18 in the 1960s. However, there have been no definitive studies clearly establishing its safety and efficacy. There are several small retrospective studies advocating the combined approach to breast ptosis,7–12 whereas others report the risks inherent in the simultaneous approach, promoting caution and consideration for staging the procedure to improve safety and quality of results.1–6 It has been suggested that the variables involved in a combination augmentation/mastopexy could lead to increased risk of poor scarring, nipple-implant malalignment, nipple malposition, or implant extrusion.5 What has often been lacking in the reported literature are clear descriptions of the perioperative decision making and surgical approach and their impact on the final result, details that might help explain the varying experiences in combination augmentation mastopexies. Regardless of physician bias, it is our experience that patients prefer a simultaneous operation to achieve a lift with augmentation, and this has been our preferred approach.
Although we have described general indications for simultaneous versus staged procedures, ultimately a combination of factors must be assessed for each individual, considering the anticipated outcome of both the surgeon and the patient. Unfortunately, there is no simple algorithm that adequately assesses the appropriate approach for each case. The most pertinent factors in our decision making included unwillingness to stop smoking at least 2 weeks before surgery, obesity, extremely large breasts requiring significant volume reduction, or severe ptosis requiring nipple-areola complex elevation greater than 6 cm.
Reflective of the propensity to stage the procedure in obese patients, 23.5 percent of the mastopexy-alone group had a body mass index greater than 30, as compared with 6 percent in the simultaneous group. One important caveat to the interpretation of results within this study is that complication rates represent only the risk associated with operations performed, while ignoring that the risk of procedures declined. For example, we found no significant correlation between smoking history or body mass index and resulting complication rate. It may be tempting to downgrade the significance of these factors. However, these results may in part be attributable to patient selection, as patients with higher body mass indexes or significant smoking history/unwillingness to quit smoking were more likely considered better candidates for a staged procedure. Indeed, of the 98 patients within this study who underwent mastopexy alone (22.8 percent), all were excluded from the simultaneous procedure either because they desired smaller, nonaugmented breasts, or because the above-mentioned selection criteria mandated a staged approach.
Reoperations were categorized as “indications for reoperation,” which was for the most part reflective of the complications seen in the study, as demonstrated by our overall complication rate of 22.9 percent and our reoperation rate of 23.2 percent. There are a couple of exceptions worth noting. There were nine reoperations for size change that were not considered complications. Likewise, in the nine cases of partial necrosis documented as a complication of this procedure, only four of these cases required reoperation, which constituted a small procedure under local anesthesia. All of these patients had very small tissue openings (<2 cm). Eight occurred in inverted-T mastopexies at the intersection of the vertical and inframammary scar and the one other case was a small opening along the incision in a circumareolar mastopexy case. There were two implant infections, both requiring explantation and subsequent reoperation for placement of a new implant. Importantly, there were no instances of disastrous complications such as major skin flap or nipple necrosis, which have been implicated when using the combined procedure.3,4
Although some have described the risk of the combined procedure as being greater than that of each individual procedure,3 our data demonstrate tissue and implant-related reoperation rates similar to the individual procedures when considered separately. We report a tissue-related reoperation rate of 13.6 percent for simultaneous augmentation/mastopexy, as compared with our measured reoperation rate of 10.2 percent for mastopexy alone observed in this study. These reoperation rates are similar to an 8.6 percent reoperation rate for mastopexy alone reported by Stevens et al.9 In addition, our implant-related reoperation rate of 9.6 percent measured for the simultaneous procedure does not appear greater than reoperation rates reported for augmentation. In the Mentor 6-year core data, a 19.4 percent reoperation rate was noted in 551 primary breast augmentation patients.19 Allergan 6-year core data demonstrated a 28 percent reoperation rate in 445 patients.20 In our study, the most common implant-related indications for reoperation were capsular contracture, implant size change, and implant malposition. These are consistent with their findings: Mentor reported capsular contracture and size change and Allergan reported capsular contracture and implant malposition as the most common indications for reoperation in primary augmentation.19,20
When comparing the reoperation rate involved in the staged procedure against that of the simultaneous procedure, the staged approach entails an inherent minimum 100 percent reoperation rate in addition to the reoperation rates for each procedure separately. This far exceeds the reoperation rate of 23.2 percent measured in this study. Although the rate of 23.2 percent for the combined procedure may seem high for a cosmetic procedure and is higher than that of either individual procedure performed alone, the reoperation rate of combining the two procedures is not more than additive when compared with published values. Likewise, our findings are within a range of other similar case series. Codner et al. reported a series of 178 simultaneous augmentation/mastopexy cases over a 15-year period with an overall reoperation rate of 25.8 percent, including 16.3 percent for tissue-related and 9.5 percent for implant-related indications.13 Stevens et al. reported an overall reoperation rate of 14.6 percent, including 10.9 percent for tissue-related and 3.7 percent for tissue-related indications.9
The efficacy of our results was not a major focus of this study and has been assessed only as a function of the reoperation rate described and as a subjective analysis of the results obtained. Photographs of patients with ptosis in both primary and secondary cases have been included as representative examples (Figs. 5 through 8). Although patient satisfaction surveys were not a part of this particular study, this additional information could provide important additional information in future studies to more clearly determine the efficacy of augmentation with a mastopexy, either simultaneously or as a staged procedure.
In our practice, patients prefer a combined procedure when an augmentation and mastopexy are required, and it has been our primary approach for the majority of patients. Although a 23.2 percent reoperation rate may be considered too high for a purely cosmetic procedure, staging the operation, which is commonly posed as the alternative, does not appear to offer any advantage of safety in the majority of cases in this study. We acknowledge the inherent difficulty posed in a combined approach, and a potential reoperation should be part of preoperative counseling with appropriate candidates for the procedure. However, with careful consideration given to the perioperative decision making and operative approach, our data demonstrate the effectiveness of a one-stage procedure with acceptable complication and reoperation rates.
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