How to successfully combine mastopexy and breast augmentation
Many knowledgeable plastic surgeons have stated that it is very difficult to combine mastopexy (breast lift) and breast augmentation into one operation. Why is this? Certainly, breast augmentation is considered by many to be a quick and easy procedure; and although mastopexy can be challenging, why should the addition of augmentation (often a very necessary part of mastopexy) make it so much more so? To understand this, one must look at the goals of the two procedures to see that they may be at cross-purposes.
The mastopexy operation is usually performed on a breast that has an excessive skin envelope due to the effects of pregnancy, aging, or weight loss; or a congenital trait or condition, such as tuberous breast, Poland’s syndrome, or pseudoptosis. In many cases, the breast tissue is fatty and somewhat amorphous with excessive, atrophic skin; and some substantial breast resection could be needed. In the congenital cases, though, the skin envelope may be taught, and the breast tissue may be glandular and constricted.
On occasion, mastopexy is needed to correct problems created by a previous breast augmentation. In short, the problems requiring mastopexy cannot always be solved by the same procedure and the same amounts of skin and breast resection. However, to some extent, the elevation of the nipple/areolar complex and the “lifting” of the breast requires some tightening of the skin envelope and repositioning of the glandular mass in an upward direction.
The goals of breast augmentation, on the other hand, are somewhat at odds with mastopexy. The most obvious is to enlarge the breast by placing an implant either under the gland itself or under the pectoralis muscle. This intentionally tightens the skin envelope and, depending on the position of the implant relative to the pectoralis, adds weight to the breast itself, further stretching the skin—or it may only augment the muscle, allowing loose skin to hang and creating a “double-bubble” effect in some cases.
Some physicians place the implant in a low position relative to the inframammary crease to give the appearance of a lift, but actually end up lowering the entire breast mound on the torso. Others handle the nipple position by a limited “pexy,” such as the crescent mastopexy, doughnut mastopexy, or the Benelli procedure. Often, this has the effect of abnormally stretching the areolar skin, while creating an abnormal breast shape with excessive roundness just above the apex of the nipple. Depending on the type of mastopexy chosen and the pedicle orientation, an implant may have some adverse impact on the circulation of the NAC pedicle.
Prior breast surgery is a factor that must be considered in the preoperative planning stages. When a previous procedure has been performed on the breasts, it may adversely affect the remaining blood supply to the NAC pedicle. The position of the inframammary crease can be lowered with a breast implant (but rarely elevated) and raised with a mastopexy (but rarely lowered). Mastopexy procedures will tighten the skin, as will an augmentation.
Overlapping Surgery Goals
The creation of any type of nipple/areolar pedicle reduces the blood supply to this pedicle, which can be further compromised by the choice of pedicle, prior surgical procedure, the position of the implant relative to the pectoralis, and the size of the implant used. Finally, the position of the inframammary crease created by the mastopexy must match the position of the implant, which is usually relative to the nipple: When the patient is standing, the center of the nipple should be at the same level as the center of the implant.
In combining the surgeries, several problems can be encountered by the overlapping goals of the two procedures. These include the following:
over-tightening of the skin envelope with the possibility of edge necrosis, dehiscence, and implant exposure;
NAC pedicle necrosis from the implant position or from overtightening;
mismatch of the new level of the IMC from the mastopexy and the lower edge of the implant. This usually creates a high-riding implant, or even a “double-bubble” effect; and
misjudging of the final size of the breasts due to the reposition of the breast tissue and the addition of an implant.
These problems, depending on the surgeon’s experience, can be quite daunting.
A panel at the April 2000 American Society of Aesthetic Plastic Surgery (ASAPS) meeting in Orlando, Fla, concluded that it is safer to perform these procedures separately; a previous panel discussion in this magazine came to the same conclusion. The postoperatively adjustable implant can help solve the dilemma presented above. The learning curve is very short,1 and the later retrieval and removal of the microinfusion port is facilitated by placing the port adjacent to any of the long incisions used in the mastopexy.
I have published several papers on the technique.2-11 My experience to date has been very favorable, with no instances of NAC pedicle necrosis, skin-edge necrosis, or wound dehiscence. However, elevated implant position, especially on the right side, has occurred in a few cases. I believe that proper planning is essential in this operation.
Careful, bilateral measurements should be made of the following breast parameters (Figure 1):
sternal notch to nipple in centimeters;
sternal notch to inframammary crease in centimeters;
internipple distance in centimeters;
distance from crease to nipple in centimeters;
width of breast at nipple level in centimeters;
width of chest as measured at inframammary crease, anterior axillary line to opposite anterior axillary line in centimeters;
circumference of chest at inframammary line in inches; and
circumference of chest at nipple level in inches.
You should also assess the elasticity of the skin (normal, flaccid, or atrophic) and the glandularity or fatty nature of the breast tissue.
Determining Breast Size
Determining the current breast size may require measuring in a soft, nonpadded bra if the breasts are very ptotic.
Take the IMC circumference in inches, and add 5 in for the strap size; if the circumference is 29 in, the strap will be 34 in. Then, the cup size is the difference between the circumference at the nipple and the IMC. An A cup has a difference of 5 in, and every subsequent inch is another cup (5 = A, 6 = B, 7 = C). If there is less than a 5-in difference, each inch less means you add another A (4 = AA, 3 = AAA). Then, to guesstimate the volume, consider each cup increment from A cup to be 200 g (A = 200 g, B = 400 g, C = 600 g). Consider AA half of A (100 g), and AAA half again (50 g). Noting these gram volumes will help in determining the implant volume; grams and cubic centimeters can be considered to be equal.
You can determine the implant size in the following manner: If the patient wishes to be a C cup and she is currently a ptotic A cup, she will need 600 cc for the C minus the 200 g she already has. However, you must also guess how much breast tissue you will remove in the mastopexy procedure, and subtract that figure from her current breast size. So, if you guess that you will remove 100 g, then she will be left with 100 g; for a C cup, she will need a 500-cc implant (600 – 100 = 500). If you check the product spec sheets, you will find that either a 425-cc or 475-cc implant will fill to 500 cc. I have learned to use the larger of the two implants, because the majority of women will want to go “larger” than their initial request.
When you choose the type of mastopexy to be performed, the amount of skin to be removed can be the determining factor, along with the degree of elevation of the NAC. Time and experience give you a comfort level with the many types of mastopexy available; but in general, the greater the skin removal and lower the NAC, the more likely that you will choose an “inverted T” procedure.
Lesser amounts of ptosis and skin removal will favor the vertical approach; and in rare instances, the Benelli12 technique may be appropriate. As for the pedicle, when an implant is to be used, the superior or superomedial pedicle will be most appropriate whether the implant is above or below the pectoralis muscle.
As to the appropriate height for the nipple, I believe that the nipple should be elevated with reference to the existing level of the IMC, not to an arbitrary distance from the IMC. That being said, the “average” nipple height is 21 cm from the sternal notch. But with a low IMC, that number could be too high; and with a high IMC (pseudoptosis), it may be too low.
After the markings are made as described by Hall-Findlay13 and Le Jour,14 the keyhole position is de-epithelialized, and the NAC is circumcised, the NAC is cut on a superior pedicle, and dissection continues down to the pectoral fascia, cutting obliquely upward so as to slightly undermine the NAC. Then, the pectoral fascia is exposed and opened along the direction of the fibers, and access to the submuscular space is obtained. With blunt and electrocautery dissection, create the implant pocket down to the marked level of the current IMC. The pocket thus created should be entirely submuscular, not “dual plane” as advocated by Tebbetts.15 The lateral dissection should go no further than the anterior axillary line.
The implant is inserted and filled temporarily to 300 cc. The implant is checked for proper seating and the muscle incision is closed, with the fill tube externalized through the muscle incision. Then, the central inferior breast tissue and attached skin are divided in the midline down to the muscle, creating two columns—lateral and medial. Each column is pulled to the midline and divided. The two shortened columns are then joined in the midline with a running two-layer closure with a heavy nonabsorbable suture. This lifts the breast mass and projects it.
Next, the “keyhole” is closed with a single, large-caliber suture, with enough saline removed to allow for a loose closure. It is important to make sure that the closure is tension-free. The fill-tube is cut, and the micro reservoir is attached. The micro reservoir is then placed into a subcutaneous pocket near the vertical incision line, closure of which is then done in two layers.
The NAC is sutured into the keyhole position, also in two layers. A drain is optional, but I prefer to use an elastic Velcro strap on the upper pole of the breasts and a bra as the final dressing. At any sign of vascular compromise of the skin along the incisions or the NAC, more fluid can be easily withdrawn.
In the usual case, filling is begun at the first postoperative visit, 1 week later. The first fill is usually 60 cc, with subsequent fills of 120 cc until the target volume is reached. I do not usually overfill to stretch the tissue, as I do with the expansion/augmentation of the breasts, when doing the mastopexy. The reservoirs are usually removed along with the fill tube as a local procedure in the office prior to 6 months, although some prefer to leave them in for long-term fluid adjustments in case of pregnancy.16
The three cases shown here illustrate the range of cases commonly encountered in mastopexy in three categories: 1) minimal ptosis and atrophy; 2) major ptosis and hypertrophy; and 3) reconstructive lift after prior augmentation.
Myron M. Persoff, MD, FACS, attended medical school at the University of Miami. He served as a flight surgeon and officer in charge of the Navy’s Paramedic Team One in the Philippines during the Vietnam conflict. He has been in private practice since 1976 in the South Florida area. He has written many papers in the plastic surgery literature concerning breast surgery, and he has been using post-operatively adjustable implants since the 1980s. He co-hosts a teaching session on the use of postoperatively adjustable implants at both the American Society of Plastic Surgeons and the American Society of Aesthetic Plastic Surgery annual meetings. He can be reached via email at [email protected].
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