Admittedly, it would be better to write on this subject in the form of a scientific paper in which one could present, chapter and verse, the risks and management of problems associated with combined augmentation and mastopexy. However, the problem is so important and so acute that an editorial needs to come first, with, it is hoped, a scientific paper to follow. During the last year or two, I have spoken at several meetings about augmentation and mastopexy, with the emphasis being more and more not so much how to do it or how to make it look good, but sincerely how to avoid mischief and major disasters. So, this editorial will deal not with how to perform combined augmentation and mastopexy but why it is a particularly tricky operation that is prone to unhappy outcomes.
Breast augmentation alone is a fairly simple operation. As plastic surgeons, we all know it comprises placing a breast implant beneath tissues that are composed of either the breast itself or the breast and some component of muscle, usually just the pectoralis major muscle. The complications of breast augmentation are relatively few in the short run; in the long run, they consist primarily of capsular contracture and device failure, both of which are not terribly frequent, occur gradually over time, and are, frankly, not often catastrophic.
Likewise, mastopexy is a relatively simple operation in which the breast is reshaped in some fashion, the nipple is usually elevated to some extent, and excess skin is redraped, repositioned, and/or removed. The complications of mastopexy are also relatively rare, with the most common or severe problems being undesirable or unattractive scarring, malposition of the nipple, and recurrent ptosis. However, when you combine these two operations, everything changes. Each operation makes the other more difficult and each operation increases the likelihood of complications from the other. When a mastopexy is performed on top of a breast augmentation, the following risks of the augmentation increase. There is an increased risk of infection because there is more soft-tissue rearrangement over the top of the implant. There is an increased risk of implant exposure because there is, again, more soft-tissue rearrangement with more incisions over the top of the implant. There is an increased risk of loss of nipple sensation because of the required simultaneous soft-tissue surgery around the nipple. There is an increased risk of malposition of the nipple because the nipple is moved at the same time the implant is placed; the nipple may wind up being too high, or even too low, in relation to the implant. There is an increased risk of malposition of the implant relative to the overlying breast because, as the implant is placed, the entire breast may be repositioned by the mastopexy. The implant may wind up being below the inframammary fold and the inframammary incision, or it may wind up being above the center of the breast and well above the inframammary fold. All these risks are increased when a mastopexy is added to a breast augmentation.
Of even greater concern, however, is the increased risk associated with the mastopexy when an augmentation is performed at the same time. Whereas a mastopexy is designed to reposition the nipple, reshape the breast, and reduce the skin envelope, an augmentation by definition enlarges the volume of the breast and expands the skin envelope. This sets up a competition that can ultimately lead to the disaster of insufficient soft tissue or skin being left after the mastopexy to cover the implant that has just been placed. This is made even more serious because not only are the soft tissue and the breast skin put under tension to some degree by implant placement but also the creation of a space for the implant devascularizes the soft tissues of the breast while at the same time stressing them. The larger the implant is and the wider the dissection, the greater the risk of devascularization of the central breast. This is especially true with subglandular positioning as compared with subpectoral placement. The risk of nipple loss would therefore be expected to be significantly greater with augmentation and mastopexy as compared with mastopexy alone. Similarly, there would be an increased risk of loss of either the mastopexy skin flaps around the areola or those that join below the areola in a vertical or transverse seam. Again, there is increased risk of loss of sensation to the nipple because of the combination of soft-tissue rearrangement and undermining of the breast off the chest wall. The potential for malposition of the nipple is likewise aggravated by the placement of an implant that is to some extent even more unpredictable in terms of its final position than is the position of the breast itself. Thus the nipple after augmentation and mastopexy may well wind up either too high or too low as compared with the breast mound, which after augmentation is in large part now the implant. In all likelihood, the scars will also be worse after an augmentation and mastopexy as compared with after a mastopexy alone because of the increased tension associated with implant placement.
In summary, whereas the complications after either augmentation or mastopexy alone are relatively infrequent and usually pretty manageable, the complications after augmentation and mastopexy combined are almost certainly more frequent and potentially disastrous. I wish that this editorial were simply a theoretical piece and that I did not have much experience to back this up. Unfortunately, during the last year or two, I have personally reviewed a half a dozen or so medical/legal matters where a combined augmentation and mastopexy resulted in a disastrous complication, usually the loss of a significant amount of tissue, including the nipple and areola. Lesser complications have included major malpositions of the nipple and extremely unattractive results, with nipples that are too large, too high, or distorted. Finally, even as I have become personally more aware of these issues and therefore more careful about how I perform these operations, I still frequently witness in my own hands just how careful one has to be when performing a mastopexy on a patient who is about to have or who has had a breast augmentation, because of the alteration to the soft tissues, the scars, the thinness of flaps, and the diminished blood supply.
This is not to say that one should not perform augmentation with mastopexy, but as the title of this editorial implies, this is a warning that this operation has a risk that is not the sum of the risk of the two individual parts but rather a substantially greater risk when these two procedures are performed either at the same time or in tandem. When performing augmentation and mastopexy, my advice is, “surgeon, beware!”