Fifty-four percent of Spear’s patients desired revision surgery, and 31% wanted more lift. Thirty-one percent of this author’s patients desired revision surgery (P = 0.184), and 14% indicated an interest in more lift (P = 0.220).
In recent decades, the vertical method swept North America to become the preference of many surgeons for mastopexy. Hall-Findlay,19 Hidalgo,16 and Lista and Ahmad20 made key technical and anatomical contributions. Hall-Findlay21 recommends this removal of an inferior wedge of tissue also in the setting of augmentation mastopexy. This author’s adaptation of the vertical method to simultaneous implants appears to be safe and address a number of concerns in the literature. Aided by 3 methods of tension management, there was no delayed healing or partial or complete nipple loss in any case. With the extra vascular layer for implant isolation, there was no sinus tract through the vertical parenchymal closure. One patient had a pulmonary embolism. This is similar to Swanson’s 0.8% rate of deep venous thrombosis in his series.22
The capsular contracture rate was only 2.9%. All other methods described in detail of vertical mastopexy with implant placement involve cut parenchymal edge closure over the implant. Swanson22 reports a capsular contracture rate of 4.8%. Since this study, we have used sizers for all final pocket manipulation followed by betadine irrigation and permanent implant placement with immediate overlying muscle suture closure isolating the implant. There have been no capsular contractures in the subsequent 37 cases. We hope to match Mladick’s11 augmentation capsular contracture rate of 0.6% that he accomplished through a periareolar approach through cut parenchyma as well using a sleeve, also closing the muscle split isolating the implant. The author practiced with Mladick 6 years and never saw a capsular contracture of his during or after this time. Wiener23 using a periareolar approach with no sleeve found a capsular contracture rate of 9.5%. It appears crucial to avoid any contact of implant to cut parenchyma.
The literature provides no other augmentation mastopexy Breast-Q outcomes for comparison. Cogliandro et al24 studying retrospectively breast reduction results of a 10-year period found satisfaction with breasts’ Breast-Q scores average well over 80 (77.1–88.9 with higher scores more severe hypertrophy). It appears that with this surgery after years, these women remain pleased to be rid of that extra weight and related symptoms. This method of augmentation mastopexy cannot offer long-term symptom relief, and with implants over time, many come to desire larger or smaller or no implants at all, affecting satisfaction with breasts. The current protocol Breast-Q results are more similar to that of breast augmentation. Gryskiewicz and LeDuc25 studying transaxillary breast augmentation found outcome satisfaction 80 (SD = 22.4) and satisfaction with breasts 76.0 (SD = 16.6).
With persistent yearly weight gain of most patients in our society, perfect size cannot be determined, correction of sag is often a matter of degree, and there is inherently significant length and visible scar, but the degree of correction and relative quality of scars along with nipple position, areola size, optimal implant size, and position are valued by patients and each deserves individual efforts. Spear’s multipoint survey reveals his insight into the need to address so many variables. He pursued this by means of skin-tightening lifts including permanent pursestrings.26 The comparison of survey results (Table 3) seems to suggest that there might have been room for improvement with the type of lift, delayed recipient preparation, and tension management, but the data from the Spear’s 2004 study was unavailable beyond the reported means and percentages, so an in-depth analysis was not possible. In the comparison, the greatest difference was amount of lift, but this and the other comparisons did not reach statistical significance.
Although 31% at up to 10 years desiring revision surgery may seem high, it compares favorably with Spear’s 54%. The author is not aware of any other study, where augmentation mastopexy patients were asked this question for any other comparison. Furthermore, it is not a revision rate but response to questions so many years postoperative. On review of the author’s 11 patients comprising the 31%, 3 patients wanted larger implants and 1 patient wanted correction of asymmetric animation deformity. A subset of the 31% is the 14% desiring more lift. There should be some recognition of the influence of aging and weight gain in an 8 year 6 month series. Recent data from Mundy et al27 on normative data for the Breast-Q reduction module indicates an association between higher body mass index and lower Breast-Q scores. Because most women gain weight over time, this must be a factor long term.
Since this study, the author began more aggressive resection below pillars of at most 8 cm height, usually converting to a “T” instead of a “J” and easily maintaining implant isolation. A persistent long distance of areola to IMF can give the impression of persistent ptosis. Swanson’s22 early revision rate for persistent ptosis was 10.3% in this setting. He lowered this by half with changes that included a wedge resection of lower pole parenchyma.
Swanson22 provides other complication and survey data: delayed wound healing in 7.1% and patient-reported dissatisfaction with scars 16.7%. With the author’s 3 modalities of tension management, there were no cases of no delayed healing and Spear’s survey patient-reported dissatisfaction with scars was 8.6%. The periareolar area is for accommodation, not lift. Scar satisfaction is likely a product of the controlled low tension environment. Furthermore, this leads to better projection and facilitates all periareolar shape and scar issues to be fixable and under local anesthesia. In contrast, some areolar size, shape, and scar issues in a setting of high postoperative skin tension have no viable surgical solution.
This repeat Spear’s questionnaire gives a rare comparison of patient impressions of saline and gel. For softness and feel, the author’s predominantly saline population compared quite favorably with gel (Table 3).
The community setting of this study comprised many mobile military, which greatly affects follow-up. The survey response could influence the result. There are limitations to the comparisons with Spear considering his was a phone survey of a series over 6 years versus the author’s mailed format for a series over 8 1/2 years. Spear used a combination of periareolar and circumvertical surgeries versus all but one breast vertical for this author. None of Spear’s surveyed patients had prior revision surgery, but 3 of the authors did and they were implant removal for weight gain, placement of larger implants (in her case planned from the initial consultation), and adjustment of areolar shape. Many more of Spear’s patients had prior breast surgery including mastopexies and implants. It is likely that this author’s patients averaged greater ptosis because during the 105 patient series over 8 years 6 months, those with severe ptosis or asymmetry were almost never diverted to 2 stages (one patient). It is not known what portion of Spear’s patients with more severe ptosis or asymmetry were diverted 2 stages. Any more than 1 such patient over his 6-year series diverted to 2 stages would make the study populations quite different.
For those planning a transition to the vertical technique over implants, 2 issues must be addressed. One is to recognize the dramatic stacking of projecting technique over projecting implant requiring more skin. Traditional tailor tacking is misleading and potentially dangerous in this setting as it is oblivious to the intervening step of wedge excision and pillar approximation. The 3 methods of tension management including 3D tailor tack completely manage these dynamics. Another consequence of the vertical method is breast narrowing and, thus, less visible breast lateral to nipple. Frontal view can give the impression of a laterally displaced nipple, more apparent in keel-shaped chests and breasts that have a more lateral footprint or rest on a narrow side of chest (see video, Supplemental Digital Content 6, which demonstrates this on her left more narrow side. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or at http://links.lww.com/PRSGO/B77).
A vertical method of mastopexy that includes unique tension management steps and complete implant isolation from cut parenchyma appears to offer advantages in softness, safety, and patient satisfaction. Breast-Q indicates this method’s high level of satisfaction. A repeat of Spear’s survey designed for augmentation mastopexy gives a more detailed look at patient-specific postoperative concerns and confirms high patient satisfaction, but a direct comparison with Spear’s skin tightening types of lifts lacks statistical significance.
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