No double bubbles were encountered. Secure approximation of the medial and lateral pillars helps prevent inferior implant displacement. For implant insertion, the author prefers a horizontal incision within the lower pole, above the existing inframammary fold, with a submuscular dissection cephalad to the inframammary ligaments.46
Technical points include (1) a willingness to “T” off the lower end of the mammaplasty when needed; (2) adequate resection of excessive lower pole parenchyma; (3) tightening of the lower pole and coning of the breast; and (4) intraoperative nipple positioning just below the apex of the breast to prevent nipple overelevation. With these adjustments, the need for revisions for persistent ptosis has dropped in half from 10.3% to 5% for the most recent 100 cases. Adequate parenchymal resection of the lower pole avoids a “mastopexy wrecking bulge”47 or a snoopy deformity. Direct excision is used rather than liposuction so as to adequately remove denser breast tissue along with fat from the lower pole and to limit tissue trauma. A 39-mm areola marking ring is preferred because the areola tends to stretch about 1 cm postoperatively.48 Women prefer areola diameters that do not exceed 5 cm.49 There was no correlation between complications and secondary mastopexies, including delayed wound healing. Women who have had previous Wise pattern mammaplasties may be safely treated using the vertical technique,20,50 provided that a wide areola attachment is preserved.
Subpectoral implant placement adds a layer of tissue cover and is preferred by most operators.6–8,10,12–16,20 However, prepectoral placement is a valid alternative, particularly in women with adequate breast tissue, and avoids an animation deformity. There is a general preference for silicone gel implants29 although some surgeons more commonly insert saline implants.6,20 Silicone gel implants have traditionally been favored for a more natural feel characteristic and possibly less rippling.35 However, in a woman who has a moderate breast volume, this difference may be negligible, particular in a subpectoral pocket. The author does not use more cohesive, form-stable implants because they have not been shown to produce a superior outcome51,52 and have disadvantages that include firmness, rotation, expense, and texturing—which is linked to late seromas, double capsules, and anaplastic large cell lymphoma.53,54 Mean implant volumes in other studies vary from 306 to 450 mL.6–8,15,16,55 In this study, the average implant volume was 372 mL, 20 mL less than the average for breast augmentations without mastopexy,18 and similar to the mean volume in the study by Calobrace et al7 (392 mL). Measurements of nipple/areola perfusion25 reveal that implant sizes up to 575 mL may be safely inserted using a vertical method and medial pedicle. It has been suggested that, logically, larger implants should have a higher complication rate.8 However, neither this study nor the study by Calobrace et al7 substantiates this claim. Larger implants correlate with greater patient satisfaction.18,49
Eighty percent of women undergoing reduction mammaplasty report that nipple sensation is important sexually.56 Regardless, sensate body parts are always to be preferred. An inverted-T pedicle sacrifices all superficial innervation to the nipple. The deep innervation is precarious and depends on the extent of the deep dissection. Courtiss and Goldwyn57 reported that 35% of women experience persistent nipple numbness 2 years after an inverted-T, inferior pedicle breast reduction–much higher than the 13.3% rate of persistent nipple numbness in the present study. Although many surgeons favor a superior or superomedial pedicle, Schlenz et al58 found that a superior pedicle compromises nipple sensation by sacrificing the deep innervation. The author prefers to maintain a parenchymal attachment deep to the nipple/areola complex in an effort to preserve deep innervation and a medial pedicle to capture the dominant medially based superficial innervation.21
The mean follow-up time was 9.4 months. Therefore, long-term complications such as implant deflation or capsular contracture are likely to be underrepresented. A specific operation is evaluated—vertical augmentation mastopexy with a medially based pedicle. Certainly, there are many variations in technique from the method described here that may achieve an optimal outcome.
No patient was selected for staged treatment, avoiding selection bias. A large patient population and consecutive patients add to the reliability of the study findings. The consistency of the same surgeon and technique avoids confounding variables. Outcome data provide valuable information from the patient’s perspective.
A simple algorithm may be used to select the treatment of women with breast ptosis and volume deficiency. The combined procedure is safe and widely applicable. Staging is unnecessary. Patient-reported outcome data are favorable, with 94.4% of patients reporting that they would repeat the surgery (See video, Supplemental Digital Content 7, which displays the entire procedure in one clip. This video is available in the “related videos” section of the full-text article on PRSGlobalOpen.com or available at http://links.lww.com/PRSGO/A323).
The author thanks Jane Zagorski, PhD, for statistical analyses; Lindsey Kroenke, BSN, Sarah Maxwell, RN, Christina Engel, RT, and Janice Ragain for data collection; and Gwendolyn Godfrey for the illustration.
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