Khavanin et al.1 reiterate the conventional view2 that a mastopexy and breast implant work at cross purposes: the mastopexy tightens the skin envelope and the breast implant expands it. Spear et al.3 opined that the risk of combined surgery was not only additive but exponential, cautioning, “surgeon, beware.”2
Nonvertical mammaplasties have important anatomical limitations.4–6 A breast implant is expected to stretch the lower pole and apply pressure on an inferior pedicle, which remains tethered at the inframammary fold, risking nipple ischemia.4 A periareolar mastopexy, paradoxically, removes tissue from the area to be stretched by the implant, not from the lower pole, where it is excessive; areola deformities and persistent ptosis are frequent problems.4,6
The design of a vertical mastopexy with a medial pedicle is much different (Fig. 1).4 The short pedicle is based superficially, where it is less susceptible to pressure because the base of the pedicle moves up with the breast mound.4,7 Eighty percent of nipple elevation derives from breast mound elevation and only 20 percent comes from nipple repositioning.7 There is less risk to nipple perfusion, even when using implant volumes in the range of 200 to 575 cc.4 Measurement data consistently favor a vertical mammaplasty.5,6 After a Wise-pattern mammaplasty, women often resemble candidates for a vertical augmentation/mastopexy (Fig. 1).4
The authors1 recognize that the mastopexy technique varied between (mostly retrospective) studies and even within studies. By contrast, my prospective patient-reported outcome study8 (n = 47) and clinical study4 (n = 146) featured only vertical augmentation/mastopexies and included cohorts of vertical mastopexy–only patients for comparison. Khavanin et al.1 evidently confused these studies, entering the limited clinical data obtained from patient surveys8 in their tables and erroneously referencing the clinical study.4 Unfortunately, the data from the larger clinical study4 were not included.
A systematic review is no more reliable than its constituent studies.1 Meta-analyses, regarded as Level I evidence, typically include only randomized trials or high-level observational studies. Complication and reoperation rates are heavily influenced by the surgeon’s definition of a complication4 and willingness to perform a revision.4,9 Major breast asymmetry is difficult to treat by mastopexy alone; it is much easier to match augmented breasts.4 Patients with very ptotic breasts are excellent candidates for augmentation/mastopexy because they typically require upper pole volume restoration. Implant volume is not a risk factor.4 Inadequate lower pole resection is usually to blame for persistent ptosis.4
Patient satisfaction after a vertical augmentation/mastopexy is 91.5 percent.8 This finding is important because it is commonly believed that augmentation/mastopexy patients are difficult and harbor unrealistic expectations.10 Vertical augmentation/mastopexy is neither inherently dangerous nor technically difficult.4 On the contrary, this combination offers at least 16 positive synergies that reduce difficulty and improve the aesthetic outcome.4 Any woman who is a candidate for augmentation and mastopexy performed individually is a candidate for the combined procedure.4 Staging is unnecessary.4 Vertical augmentation/mastopexy patients are no more discriminating than other cosmetic breast surgery patients and report similarly high levels of patient satisfaction.8 The new mantra? Augmentation/mastopexy: surgeon, embrace.
The author has no financial interest to declare in relation to the content of this communication. There was no outside funding for this study.
Eric Swanson, M.D.
11413 Ash Street
Leawood, Kan. 66211
1. Khavanin N, Jordan SW, Rambachan A, Kim JY.. A systematic review of single-stage augmentation-mastopexy. Plast Reconstr Surg. 2014;134:922–931
2. Spear S.. Augmentation/mastopexy: “Surgeon, beware”. Plast Reconstr Surg. 2003;112:905–906
3. Spear SL, Dayan JH, Clemens MW.. Augmentation mastopexy. Clin Plast Surg. 2009;36:105–115
4. Swanson E.. Prospective comparative clinical evaluation of 784 consecutive cases of breast augmentation and vertical mammaplasty, performed individually and in combination. Plast Reconstr Surg. 2013;132:30e–45e; discussion 46e–47e
5. Swanson E.. Comparison of vertical and inverted-T mammaplasties using photographic measurements. Plast Reconstr Surg Glob Open. 2013;1:e89
6. Swanson E.. A retrospective photometric study of 82 published reports of mastopexy and breast reduction. Plast Reconstr Surg. 2011;128:1282–1301
7. Swanson E.. Prospective photographic measurement study of 196 cases of breast augmentation, mastopexy, augmentation/mastopexy, and breast reduction. Plast Reconstr Surg. 2013;131:802e–819e
8. Swanson E.. Prospective outcome study of 106 cases of vertical mastopexy, augmentation/mastopexy, and breast reduction. J Plast Reconstr Aesthet Surg. 2013;66:937–949
9. Pollock H, Pollock T.. Is reoperation rate a valid statistic in cosmetic surgery? Plast Reconstr Surg. 2007;120:569
10. Spear SL, Pelletiere CV, Menon N.. One-stage augmentation combined with mastopexy: Aesthetic results and patient satisfaction. Aesthetic Plast Surg. 2004;28:259–267
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