Requirements for Optimal Correction in Glandular Ptotic and Constricted Lower Pole Breasts

Glandular ptotic breasts and constricted lower pole breasts have significant anatomic differences, but optimal correction of both deformities with augmentation has common requirements

Glandular ptotic breasts and constricted lower pole breasts have significant anatomic differences, but optimal correction of both deformities with augmentation has common requirements (Table 19-1): (1) surgical correction of the anatomic layer(s) that produce the deformity, (2) selection of implant type and size that allows the surgeon to control distribution of fill and pressure that the implant exerts on adjacent tissues, (3) redistribution or repositioning of tissue relative to the implant, (4) tissue layer interface control, (5) precise intraoperative control of implant pocket dimensions, and (6) precise positioning of the implant within the soft tissue pocket.

Table 19-1 Requirements for correction of glandular ptotic and constricted lower pole breasts

Requirement for Correction	Reason(s) for the Requirement
1. Surgical correction of the anatomic layer(s) that produce the deformity	Glandular ptosis (GP): must disrupt and convert the parenchyma–muscle interface to a parenchyma–anterior capsule interface Constricted lower pole (CLP): Must release constricting tissue layers to allow subsequent stretch by implant forces
2. Selection of implant type and size that allows the surgeon to control distribution of fill and pressure that the implant exerts on adjacent tissues	GP: Requires full height, moderate projection implant selected using the High Five™ System in order to exert maximal pressure over the greatest surface area of the posterior parenchymal surface CLP: Same as GP; in addition, exert widest (not focal) pressure across the entire lower pole area of soft tissue constriction—all layers
3. Redistribution or repositioning of tissue relative to the implant	GP: Must redistribute parenchymal mass over the widest surface area to provide maximal opportunity for the posterior surface of the parenchyma to attach to the anterior capsule to provide support to minimize inferior descent CLP: Parenchyma, often constricted with minimal base width, needs to be redistributed more widely by radial and/or concentric scoring to redistribute the parenchymal mass over as wide an area of the implant as possible for coverage and for optimal aesthetics
4. Tissue layer interface control	GP: Disrupt existing parenchyma–muscle interface that allowed inferior migration of parenchyma; establish widest possible surface area for attachment of redistributed parenchyma to anterior capsule CLP: Release/disrupt attachments at the parenchyma–muscle interface to allow subsequent redistribution of narrow, constricted parenchymal mass; provide maximal surface area for implant to exert pressure on overlying constricted soft tissue layers to effect stretch to reform and reshape the lower pole
5. Precise intraoperative control of implant pocket dimensions	GP: Implant pocket dimensions control implant position; implant position is critical to exert pressure and provide controlled fill in specific areas CLP: Same as for GP
6. Precise positioning of the implant within the soft tissue pocket	GP: Implant position within the pocket is critical to exert pressure and provide controlled fill in specific areas for optimal correction. CLP: Same as for GP

Categorizing Breast Ptosis

The most commonly recognized classification of breast ptosis was first published in 1976 by Paula Regnault.¹ This classification and subsequent modifications of the classification, while useful for many years, share common deficiencies that confuse many surgeons and contribute to selection of suboptimal surgical techniques for correction.

All current classifications of breast ptosis that relate the position of the nipple to the level of the projected inframammary fold are extremely subjective, non-quantitative, and subject to a wide range of surgeon interpretations. Absent measurements to quantify the amount of skin in the lower pole of the breast (nipple-to-inframammary fold distance measured under maximal stretch ^2,³) surgeons make judgments and select techniques for correction by viewing the breast laterally in photographs or in the clinical setting, and subjectively assign a level of the nipple relative to the level of the projected inframammary fold anteriorly. This method, though widely used, is exceedingly inaccurate and subject to a wide range of variables. When surgeons use this method, and then select a surgical technique for correction of the deformity based on a subjective and relatively inaccurate and inconsistent visual estimation, it is not surprising that a large number of suboptimal corrections and subsequent revision or reoperation procedures occur.

Surgeons should recognize the critical importance of establishing quantitative guidelines to define degrees of breast ptosis that may be correctable by an implant alone versus degrees of ptosis that require mastopexy, with or without augmentation. The single quantitative factor that best defines whether a breast implant alone may correct a ptosis deformity is nipple-to-inframammary fold distance measured under maximal stretch (N:IMF_{max stretch}). When N:IMF exceeds 9.5 cm and/or breast width exceeds 13 cm, surgeons should not attempt correction of the ptosis deformity with an implant alone.^2,³ Figure 19-1 emphasizes the need to strongly consider mastopexy when N:IMF measured under maximal stretch exceeds 9.5–10 cm.

Figure 19-1 Criteria for mastopexy in lieu of augmentation in the glandular ptotic breast.

When N:IMF exceeds 9.5 cm and/or breast width exceeds 13 cm, surgeons should not attempt correction of the ptosis deformity with an implant alone

The most accurate, reproducible, and scientifically valid method of classifying and quantifying the degree of ptosis is a single measurement: nipple-to-inframammary fold distance measured under maximal stretch. This measurement not only serves as a criterion for performing mastopexy in lieu of or in conjunction with augmentation as described previously, but it also provides an objective method of documenting degree of lower pole skin stretch preoperatively and at intervals postoperatively. Objectively documenting further stretch following augmentation or mastopexy provides surgeons with objective evidence to document positive or negative postoperative changes that may become issues to patients.

The degree to which an implant is likely to accomplish optimal correction of a sagging breast is determined by the amount of skin in the lower pole of the breast (N:IMF_{max stretch}) and the amount of filler material required to optimally and fully expand the lower pole. The longer the N:IMF measurement, the wider the breast, and the less parenchyma present preoperatively, the greater the implant volume required to optimally expand the skin envelope and create adequate projection to optimally correct the deformity.

The less parenchyma present in a patient’s breast, the lower the nipple position may appear for any N:IMF measurement. Traditional classifications of ptosis that base technique selection on nipple position relative to the projected inframammary fold do not consider three critical factors that determine whether an implant alone may accomplish optimal correction: N:IMF_{max stretch}, base width (BW), and the amount of parenchyma present within the existing envelope.

Using quantitative measurements to define limits for augmentation alone versus mastopexy (with or without an implant) eliminates the inherent inaccuracies of subjective judgments of nipple position relative to the inframammary fold.^2,³ Ptosis deformities in which the nipple–areola complex is located 1–1.5 cm below the level of the projected inframammary fold, indicate formal mastopexy according to most systems that classify ptosis using nipple position relative to the projected inframammary fold. A subset of these cases, however, has a low nipple position relative to the inframammary fold, but may have a N:IMF of 8.0–9.0 cm or less, indicating that the deformity is likely correctable by implant alone, avoiding unnecessary tradeoffs and risks of mastopexy. In subjective terms, a patient can have an “empty” breast that appears “sagging”, but if N:IMF is 9.5 cm or less and base width is 13 cm or less, the “emptiness” factor that is causing the sagging appearance can likely be corrected with an implant alone. When N:IMF and BW exceed the previously defined parameters, the volume of implant required to optimally expand the envelope for optimal correction becomes excessive, often exceeding 400–500 cc, and surgeons should counsel the patient regarding the tradeoffs of excessively large, low breasts compared to the tradeoffs of mastopexy.

The Glandular Ptotic Breast

The generic term “glandular ptotic” is inherently subjective and poorly defines one segment of a range of breast ptosis deformities. Three components must exist simultaneously to create a glandular ptotic or ptotic breast: (1) weakness or stretch of soft tissue attachments at the parenchyma–muscle interface, (2) a mobile mass of parenchyma, and (3) excess skin (by stretch) in the lower pole envelope to allow descent of the parenchymal mass. Descent of the nipple–areola complex is a separate component, and the extent to which the complex descends depends on the degree of stretch in the skin of the upper breast envelope.

The degree to which the nipple-to-inframammary fold skin stretches to lengthen N:IMF and the quality of the soft tissue attachments at the parenchyma–muscle interface determine the degree to which the glandular mass migrates inferiorly

In the glandular ptotic breast, the tissue interface between the pectoralis major muscle and the overlying breast parenchyma is extremely mobile, allowing the parenchyma to migrate inferiorly over time or following pregnancy. Stretched skin is present in the lower pole envelope that allows descent of the parenchymal mass. The degree to which the nipple-to-inframammary fold skin stretches to lengthen N:IMF and the quality of the soft tissue attachments at the parenchyma–muscle interface determine the degree to which the glandular mass migrates inferiorly.

Criteria for Augmentation without Mastopexy for Correcting the Glandular Ptotic Breast

Theoretically, the nipple–areola complex (NAC) in the glandular ptotic breast is located at or above the level of the anteriorly projected inframammary fold (Figure 19-2). The position of the nipple with respect to the projected inframammary fold, as previously discussed, does not accurately define the variables that affect correction of this type of breast deformity. For example, the nipple can appear to be below the level of the projected inframammary fold, but N:IMF may be only 8–8.5 cm if minimal parenchyma is present. This degree of lower pole stretched envelope certainly does not require a mastopexy for optimal fill and aesthetic correction. A 300 cc breast implant in conjunction with a dual plane type 2 pocket dissection predictably corrects this deformity without subjecting the patient to all of the tradeoffs and risks of a mastopexy.

Figure 19-2 Nipple position at level of projected inframammary fold in the glandular ptotic breast.

Analyzing this type of deformity using the High Five™ System ³ quickly identifies and quantifies indications for augmentation alone or mastopexy (Table 19-2).

Table 19-2 Applying the High Five™ System to determine the necessity of mastopexy or augmentation alone

According to the system, a 13 cm base width requires 325 cc volume for optimal fill. If anterior pull skin stretch (APSS) exceeds 3 cm, as it virtually always does with a stretched envelope (glandular ptotic) breast, the system recommends adding 30 cc to the starting volume for a total of 355 cc. If APSS exceeds 4 cm, an additional 30 cc or a 385 cc volume would be required. Finally, if N:IMF exceeds 9.5 cm, the system recommends adding another 30 cc for a total of 415 cc. While this size implant may adequately expand the lower pole envelope and improve appearance, even this significant volume may not adequately fill the upper pole of the breast. Regardless, this weight implant in an envelope that has already proved it stretches excessively as a result of genetics, aging, or pregnancy, is unlikely to sustain a satisfactory aesthetic result at best, and at worst could quickly develop a “rock in a sock” appearance of a much larger breast that appears low on the torso. Rationale for implant type selection and level of the inframammary fold in this example are discussed later in this chapter.

No breast implant lifts a breast

No breast implant lifts a breast. When treating significant glandular ptosis with an implant alone, patients should be informed and acknowledge in written, informed consent documents that their result will be a substantially larger breast that remains low on the torso, likely with poor fill of the breast upper pole.

Informed Consent Considerations for Patients with Glandular Ptosis

Most patients with glandular ptosis, if presented with alternatives, prefer augmentation alone, avoiding the scars and other potential tradeoffs of mastopexy. In order to obtain valid, legal informed consent, however, patients who select augmentation and decline mastopexy should understand and acknowledge the following in written and signed informed consent documents:

1. The surgeon must place adequate volume (a large enough implant) to adequately fill the breast envelope, or the middle and upper breast will not be adequately filled, and the breast may have a “rock in a sock” appearance.

2. The very fact that the breast is sagging preoperatively proves that the genetic qualities of the skin were unable to support the weight of the breast alone without excessive stretching.

3. Adding weight, especially the weight of an implant large enough to fill an already stretched envelope, to a breast that has already proved it stretches excessively is at best a temporary improvement, and any correction achieved may be lost rapidly due to further stretch of the skin with the added weight of an implant.

4. No implant in this type breast, regardless of type or size, will predictably maintain fill in the upper breast. Mastopexy, with or without augmentation, will also not predictably maintain fill in the upper breast. Patients with skin that has already stretched excessively should be aware that despite some surgeons’ claims, no implant or technique will ever change the genetic realities of the skin, and therefore the patient should never expect long-term upper breast fill.

No implant in this type breast, regardless of type or size, will predictably maintain fill in the upper breast. Mastopexy, with or without augmentation, will also not predictably maintain fill in the upper breast

5. No breast implant effectively lifts a breast. Filling the envelope may create an appearance of nipple lift, but any lifted appearance is more apparent than real. True lifting of the breast requires removal of excess stretched skin that allowed downward displacement of the breast tissue that created the ptosis.

6. Augmenting a breast with a stretched lower pole envelope can often result in a breast that appears “bottomed”, fuller in the lower breast and emptier in the upper breast, with or without an excessively upward tilted or located nipple–areola complex.

7. Augmenting a glandular ptotic breast results in a larger breast that may continue to appear low on the torso. Augmentation in this type breast never produces a “perkier” appearing breast that appears higher on the torso.

8. Mastopexy may be required as a secondary procedure for any patient with a significant degree of glandular ptosis who is treated with augmentation alone.

Implant–Soft Tissue Dynamics in the Glandular Ptotic Breast

The key to success or failure in treating glandular ptotic breasts with augmentation alone is the posterior interface of the parenchyma with either the anterior capsule in submammary, subfascial, or dual plane ⁴ 2 augmentations, or the parenchyma–muscle interface if the surgeon places the implant subpectorally. Traditional subpectoral augmentation, leaving pectoralis origins intact along the inframammary fold, is almost predictably doomed to failure, because the surgeon has not addressed the weak attachments at the parenchyma–muscle interface that allowed the glandular tissue to slide inferiorly to create the preoperative deformity of glandular ptosis. A traditional subpectoral augmentation almost predictably results in the parenchyma sliding inferiorly off the pectoralis and underlying implant to create a “double bubble” deformity in the breast lower pole. Correction of the “double bubble” deformity requires either: (1) a conversion to a dual plane⁴ 2 pocket with division of pectoralis origins along the inframammary fold and separation of parenchyma–muscle attachments to allow superomedial rotation of the lower pectoralis edge (this option optimizes soft tissue coverage medially and superiorly), or (2) conversion to a submammary or subfascial pocket which does not provide as good long-term soft tissue coverage medially and superiorly. With either conversion option, radial scoring of any palpable banding transversely at the level of the preoperative inframammary fold is often necessary for optimal release and correction.

Regardless of whether a surgeon chooses to augment the glandular ptotic patient using a submammary, subfascial, or dual plane ⁴ 2 pocket, the surgeon must realize and inform the patient that the glandular tissue may unavoidably slide downward off the anterior surface of the anterior capsule that forms around the implant. No type of implant, regardless of surface characteristics, shape, or profile/projection can predictably assure that glandular tissue will not continue to slide inferiorly off the capsule. If inferior descent of glandular tissue occurs despite a properly performed dual plane⁴ 2 or 3 pocket, or following submammary or subfascial placement, correction will require formal mastopexy to remove skin from the lower envelope (excess skin envelope is present by definition if the parenchymal mass descends, and the excess is both vertical and horizontal). Surgeons should be especially cautious when attempting to correct this secondary deformity, and assure adequate removal of skin vertically in the breast lower pole. Mastopexy techniques that limit scars to periareolar and vertical usually fail to correct this secondary deformity because they fail to remove adequate skin from the breast lower pole, choosing to rotate excess skin upward to minimize scar length.

Surgical Correction of the Glandular Ptotic Breast

Figure 19-3 is a flowchart that summarizes alternatives for surgical correction of the glandular ptotic breast.

Figure 19-3 Surgical correction of the glandular ptosis.

Provided that N:IMF is 9.5 cm or less, and base width 13 cm or less, a dual plane type 2 pocket dissection and a full height, form stable, moderate profile implant selected according to the High Five™ system ³ provides excellent correction and optimal long-term outcomes in a majority of cases. Submammary and subfascial pocket locations are not best for the patient long-term, because neither provides maximal soft tissue coverage medially and superiorly for the patient’s lifetime, risking reoperations or uncorrectable deformities such as visible implant edges and traction rippling medially or superiorly. A dual plane type 2 or 3 pocket provides optimal correction and optimal long-term soft tissue coverage for most areas of a glandular ptotic breast. Disrupting the parenchyma–muscle interface by using the dual plane⁴ 2 technique is critically important to minimize risks of the parenchyma sliding inferiorly off the muscle. With the dual plane 2, the inferior cut edge of the pectoralis moves superiorly by superomedial rotation to the level of the nipple or lower border of the areola. Details of technique are included in Chapters 8 and 11.

Submammary and subfascial pocket locations are not best for the patient long-term, because neither provides maximal soft tissue coverage medially and superiorly for the patient’s lifetime

A dual plane type 2 or 3 pocket provides optimal correction and optimal long-term soft tissue coverage for most areas of a glandular ptotic breast

An inframammary incision approach provides the most exposure, control, and versatility for adjusting the position of the pectoralis for a dual plane ⁴ 2 or 3 pocket

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