Augmentation mastopexy has proven to be one of the most difficult breast procedures plastic surgeons currently perform. There are several reasons for this. First is the fact that nearly every variable that determines the ultimate shape of the breast is being manipulated to some degree, including breast position, inframammary fold location, breast skin envelope surface area, position of the nipple-areola complex (NAC), and breast volume. All of this is performed through the most limited scar pattern possible, and it must all be done so as to create the same result on each side, despite the fact that more often than not there was preoperative asymmetry to start with. Second is that the procedure is an aesthetic operation, and patient expectations are generally exceedingly high and tolerance for complications low. Lastly, the procedure involves the use of breast implants in all their various sizes, shapes, compositions, and textures, and all of the potential complications associated with the use of breast implants also come into play. Given all of these variables, which must be managed to optimal effect, it would seem that augmentation mastopexy would be a daunting task. However, when each of the most common potential pitfalls associated with the procedure is analyzed, sound surgical solutions geared toward complication avoidance can be developed. The end result is a consistent, reliable approach that can be applied to any patient seeking an improved breast appearance via augmentation mastopexy.

In most instances the decision to perform the augmentation is the most straightforward of all the decisions involved because a general size increase to the breast is desired by most patients. What becomes difficult to gauge is when a mastopexy will be required to obtain the most aesthetic result. Certainly a small degree of persistent ptosis may be tolerated by some patients, especially when the alternative is additional scars from mastopexy (Fig. 123.1). However, generally speaking, when the location of the nipple is at or below the level of the fold, some type of mastopexy will be required to achieve an acceptable result. All that needs to be determined at that point is what type of skin envelope procedure will be required to both lift the NAC and reshape the breast. This skin tightening can range from a simple periareolar procedure, to a circumvertical approach, and finally to a full inverted T-type procedure. One caveat to this approach relates to the inframammary fold. In patients who are just on the verge of needing a mastopexy, lowering the inframammary fold can position the breast implant lower on the chest wall just enough to restore harmony between the NAC and the breast mound, and thus avoid the need for additional scarring with the mastopexy. The effect of this strategy can be optimized when an anatomically shaped cohesive gel implant is used due to the fact that the upper pole of the breast can be reshaped without creating an excessive upper pole bulge (Fig. 123.2).

Where to place the breast implant with regard to the pectoralis major muscle remains a particular area of controversy in augmentation mastopexy. In evaluating how to best make this decision, it is helpful to ask, what is the breast implant designed to accomplish? The breast implant functions as a soft-tissue filler. The size, shape, consistency, and texture of the implant will all be chosen to help fill out the skin envelope to the best effect. To this end, any restricting force that prevents the breast implant from delivering the desired shape must be minimized. The pectoralis major is one such potential restricting force, along with previous scar in revisionary cases, and tight breast capsules in tuberous breast cases. To prevent such restriction, either the muscle is released along the inframammary fold when using a subpectoral pocket until no further lower pole tightness is present or a subglandular pocket can be used. Either strategy can be successful. It is advisable to use the partial subpectoral pocket in thin patients where the soft-tissue thickness of the upper pole is less than 2 cm because the muscle will help volumetrically to create a smooth contour in the superior pole of the breast and prevent an obvious step off between the implant and the chest wall. These patients must be informed, however, that there will be breast animation with pectoralis muscle contraction (Fig. 123.3). Although this is well tolerated by most patients, in many of the revisionary patients I see, this finding is a particular area of concern and a frequent source of overall dissatisfaction with their result. In patients who have adequate upper pole tissue thickness, it is my preference to use the subglandular pocket. With this strategy, the force of the implant is more directly delivered to the overlying soft tissue and a more effective lift effect is the result. Care must be taken to avoid injuring the medial intercostal perforators no matter which pocket is developed because these vessels are a vigorous source of vascularity for the breast (1). With the subglandular pocket, I have not observed any difference in the capsular contracture rate as compared to the partial subpectoral pocket, an observation that is likely due to improvements in implant construction over the last decade.

As further evidence becomes available regarding the safety of silicone gel breast implants, restrictions on their use have
relaxed, and now gel implants can be used in conjunction with mastopexy according to the guidelines of several studies sponsored jointly by the Food and Drug Administration and the implant manufacturers. As a result, virtually any breast implant can reasonably be used in augmentation mastopexy. With such an assortment of available devices, experience has shown that certain observations can be made. For most patients, a smooth, round device, either saline or silicone, will provide an adequate shape to the breast (Fig. 123.4). Silicone gel, however, due to its increased cohesiveness and the ability to create “soft” wrinkles, can create a more natural-feeling result than saline. This difference will become more obvious in thinner patients where the implant makes up the major portion of the volume of the breast. In addition, in thinner patients, an anatomically shaped implant can create a more pleasing upper pole than a round implant. This difference between round and anatomic is more profoundly demonstrated in silicone gel devices as opposed to saline devices. Recent implant designs where a markedly cohesive gel is formed into an aggressive anatomic shape have produced outstanding results (Fig. 123.5). These types of devices are particularly useful in augmentation mastopexy where control of the upper pole of the breast can be difficult.

Surface texturing of silicone gel breast implants was developed in an attempt to reproduce the outstanding results obtained with polyurethane-coated devices with regard to reducing the capsular contracture rate (2,3). The polyurethane effect was a biochemical one where gradual degradation of the foam lattice scaffold resulted in a chronic low-grade inflammatory response in the capsule. The net effect of this was to keep the capsule from contracting, although exactly how this occurred remains unknown. Unfortunately, surface texturing of silicone gel implants does not reproduce this same biochemical effect. This at least partly explains why clinical results with textured silicone gel implants have been mixed with regard to reducing the capsular contracture rate. Both textured and smooth devices can be used successfully in augmentation mastopexy depending on physician preference. What textured silicone surfaces do accomplish is a more active interface between the capsule and

the implant. At times, the capsule can actually “grow” into the more aggressively textured devices. Whether in-growth occurs or not, all textured surfaces provide increased friction between the implant and the capsule. This feature becomes important when using anatomically shaped devices because the interaction between the capsule and the implant surface can help to keep these asymmetric implants properly oriented and help resist rotation. For this reason, all anatomically shaped breast implants, whether saline or silicone, are manufactured with textured surfaces.